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Jameson, Robert M.

Case #4882-OAOct 24, 2023$2,440.00

Selected ICD-10 Codes

Verification of M1021/M1023 placement

Primary (M1021)Required

P
L89.153Pressure ulcer of sacral region, stage 3

Secondary (M1023)(1 / 25)

1
E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified

Clinical Assessment Notes

Admitting Diagnosis

Patient presents with stage 3 chronic pressure ulcer of the sacral region. Wound measures 4.5cm x 3.2cm. Evidence of purulent drainage and peripheral erythema noted during home visit on 10/24.

Secondary findings include history of Type 2 Diabetes Mellitus with peripheral neuropathy. Patient reports significant pain (8/10) during dressing changes.

Patient is currently non-ambulatory and requires maximum assistance for repositioning. Respiratory status stable on room air.