Pressure ulcer of right lower back, stage 2

This code identifies a pressure injury located on the right lower back that involves partial-thickness skin loss. It typically presents as a shallow open ulcer with a red-pink wound bed, without slough, or as an intact or ruptured serum-filled blister. This stage indicates damage to the epidermis and/or dermis.

Apply this code when documentation explicitly states a stage 2 pressure ulcer on the patient's right lower back. Supporting clinical notes should describe the wound characteristics consistent with partial-thickness skin loss, such as a shallow ulcer or blister. This code is appropriate for both initial and subsequent encounters for this specific pressure injury.

• Ensure laterality (right) and anatomical site (lower back) are clearly documented to support this specific code.
• Distinguish from unstageable pressure ulcers (L89.139) if slough or eschar obscures the wound bed, preventing accurate staging.
• Always sequence this code after any underlying condition or cause of the pressure ulcer, if applicable.