Pressure ulcer of right upper back, unstageable

This code signifies a pressure injury located on the right upper back that cannot be clinically staged. This typically occurs when the extent of tissue damage is obscured by slough or eschar, preventing a definitive assessment of depth.

Apply this code when documentation clearly indicates a pressure ulcer on the patient's right upper back and explicitly states it is "unstageable" due to non-removable necrotic tissue. This is appropriate for initial encounters or subsequent encounters where the ulcer remains unstageable.

• Ensure the documentation specifies "right upper back" and "unstageable."
• Do not use this code if the ulcer is debrided and a stage can then be determined; instead, code to the appropriate stage.
• Always sequence this code after any underlying condition or cause of the pressure ulcer.