Pressure ulcer of right lower back, unstageable

This code signifies a pressure-induced localized injury to the skin and underlying tissue on the right lower back (sacral region) where the full extent of tissue damage cannot be determined because it is obscured by slough or eschar. The depth of the ulcer is unknown, but it is presumed to be at least a Stage 3 or 4 injury.

Apply this code when documentation clearly indicates a pressure ulcer on the patient's right lower back that is covered by non-viable tissue (slough or eschar), preventing accurate staging. The medical record must specify the anatomical location as the right lower back and confirm the unstageable status.

• Ensure the documentation explicitly states "unstageable" and specifies the right lower back as the anatomical site.
• Do not use this code if the ulcer can be staged (e.g., Stage 1, 2, 3, 4, or deep tissue injury).
• Always sequence this code after any associated underlying conditions, such as immobility or malnutrition, if applicable.