Pressure ulcer of right upper back, stage 3

This code signifies a full-thickness skin and tissue loss involving the right upper back, extending into the subcutaneous fat but not through the fascia. It presents as a deep crater with or without undermining or tunneling, and bone, tendon, or muscle are not exposed.

This code is appropriate when documentation specifies a pressure ulcer located on the right upper back that has progressed to stage 3. Clinicians should clearly document the anatomical site, the presence of full-thickness tissue loss, and the absence of exposed bone, tendon, or muscle.

• Always confirm the specific anatomical location (right upper back) and the documented stage (stage 3) from the medical record.
• Distinguish from unstageable pressure ulcers where the extent of tissue damage cannot be confirmed due to slough or eschar.
• Code any associated complications, such as infection, with additional codes.