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56 yo woman admitted to acute-care facility from SNF and has multiple sclerosis and hypertension. During course of hospitalization, decubitus ulcer is found and debrided at bedside by phys. There is no typed op report and no path report. The coder should:

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1. 56 yo woman admitted to acute-care facility from SNF and has multiple sclerosis and hypertension. During course of hospitalization, decubitus ulcer is found and debrided at bedside by phys. There is no typed op report and no path report. The coder should:





 
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