Pressure ulcer of left upper back, stage 3

This code signifies a full-thickness skin and tissue loss involving the left upper back, extending to subcutaneous fat. The ulcer presents as a deep crater with possible undermining or tunneling, but bone, tendon, or muscle are not yet exposed.

Apply this code when documentation clearly indicates a pressure ulcer located on the patient's left upper back, specifically identified as Stage 3. Supporting documentation should include the anatomical site, laterality, and the confirmed stage of the pressure ulcer.

• Always confirm the specific anatomical site and laterality (left upper back) from the medical record.
• Ensure the documentation explicitly states "Stage 3" or provides a clinical description consistent with a Stage 3 pressure ulcer.
• Do not use this code for unstageable pressure ulcers or those involving bone, tendon, or muscle exposure (Stage 4).