Pressure ulcer of right lower back, stage 4

This code signifies a severe pressure injury located on the right lower back, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, and often includes undermining and tunneling.

Apply this code when documentation clearly identifies a stage 4 pressure ulcer specifically on the patient's right lower back. Supporting documentation must detail the location, the full-thickness tissue loss, and the exposure of underlying structures.

• Always confirm the specific anatomical site (right lower back) and the stage (stage 4) from the provider's documentation.
• Do not confuse with unstageable pressure ulcers, which have obscured wound beds.
• 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.