Pressure ulcer of right upper back, stage 4

This code signifies a severe pressure injury located on the patient's right upper back. A stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle, often with slough or eschar present. This indicates significant tissue damage requiring intensive medical management.

Use this code when documentation clearly identifies a pressure ulcer on the right upper back that has progressed to stage 4. Supporting documentation should detail the location, the full-thickness tissue loss, and the involvement of underlying structures. This code is appropriate for both initial encounters and subsequent care of the stage 4 ulcer.

• Ensure the documentation specifies "right upper back" and not a general back location.
• Verify the stage is explicitly documented as "stage 4" or described with characteristics consistent with stage 4.
• Always sequence the pressure ulcer code after any underlying condition that contributed to its development, if applicable.