Pressure ulcer of unspecified part of back, stage 1

This code describes a pressure ulcer (also known as a decubitus ulcer or bed sore) located on an unspecified part of the patient's back, which is categorized as stage 1. A stage 1 pressure ulcer presents as intact skin with non-blanchable redness, typically over a bony prominence, and may be accompanied by pain, firmness, or warmth.

Use this code when documentation clearly indicates a stage 1 pressure ulcer on any part of the back (e.g., sacrum, coccyx, scapula) without further specification of the exact anatomical site. This applies to initial encounters or subsequent encounters where the ulcer remains at stage 1. Documentation should explicitly state "stage 1" and "pressure ulcer of the back."

• Do not use this code if the specific anatomical location on the back (e.g., sacral, coccygeal) is documented; use a more specific code from the L89.1- subcategory.
• Ensure the documentation explicitly states "stage 1" and "pressure ulcer." If the stage is not documented, query the provider.
• This code is for the unspecified part of the back. If the back location is known, select the appropriate specific code (e.g., L89.131 for sacral).