Pressure-induced deep tissue damage of left upper back

This code signifies a severe form of pressure injury affecting the left upper back, characterized by intact skin with underlying tissue damage. It indicates a suspected deep tissue injury (sDTI) where the extent of tissue damage is not yet fully visible on the skin surface. The injury typically presents as a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Apply this code when documentation clearly identifies a pressure-induced deep tissue injury on the patient's left upper back. This diagnosis is supported by findings such as persistent non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister, in the specified anatomical location, where the full extent of tissue loss cannot be determined.

• Do not use this code for open pressure ulcers or other stages of pressure injury; it is specific to deep tissue damage with intact skin.
• Ensure documentation specifies "left upper back" and "deep tissue damage" or "suspected deep tissue injury."
• Sequence this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity.