Pressure ulcer of right lower back, stage 3

This code signifies a full-thickness skin and tissue loss involving damage or necrosis of subcutaneous tissue, extending down to, but not through, underlying fascia, located on the right lower back (sacral or coccygeal region). It typically presents as a deep crater with or without undermining or tunneling.

Apply this code when documentation clearly indicates a pressure ulcer on the patient's right lower back that has progressed to Stage 3. This includes ulcers with visible subcutaneous fat, but without exposed bone, tendon, or muscle. Supporting documentation would include wound care notes, physician assessments, and nursing records detailing the ulcer's location, depth, and characteristics consistent with Stage 3.

• Ensure the documentation specifies "right lower back" and not just "lower back" or "sacrum" to avoid laterality errors.
• Verify the stage is explicitly documented as "Stage 3" or described with characteristics unequivocally meeting Stage 3 criteria.
• Do not use this code if the ulcer involves exposed bone, tendon, or muscle; a higher stage code would be appropriate.