Pressure ulcer of left upper back, stage 4

This code represents a severe pressure injury located on the left upper back, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, or damage to underlying structures.

Use this code when documentation clearly specifies a pressure ulcer on the left upper back that has progressed to stage 4. This typically involves a wound assessment by a physician or wound care specialist detailing the depth and tissue involvement consistent with stage 4 criteria.

• Ensure the documentation explicitly states "left upper back" and "stage 4" for accurate coding.
• Do not use this code for unstageable pressure ulcers; those have their own specific codes.
• Always sequence this code after any associated underlying conditions, such as immobility or malnutrition, if applicable.