Pressure ulcer of right upper back, stage 2

This code signifies a pressure-induced skin and tissue injury located on the right upper back, characterized by partial-thickness skin loss involving the epidermis and/or dermis. It typically presents as a shallow open ulcer with a red-pink wound bed, without slough, or as an intact or ruptured serum-filled blister.

Apply this code when documentation clearly indicates a stage 2 pressure ulcer affecting the right upper back region. Supporting documentation should include the specific anatomical location, the confirmed stage of the ulcer, and a description consistent with partial-thickness skin loss. This code is appropriate for both initial encounters and subsequent care of this specific wound.

• Ensure the documentation specifies "right upper back" and not a more general "back" or "shoulder" area.
• Verify the stage is explicitly documented as "stage 2" or described with characteristics unequivocally meeting stage 2 criteria.
• Do not use for unstageable pressure ulcers, deep tissue injuries, or other stages of pressure ulcers.