Pressure ulcer of left lower back, stage 3

This code signifies a deep pressure injury located on the left lower back, characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, the underlying fascia, presenting as a deep crater. Bone or tendon is not yet exposed.

Assign this code when documentation clearly indicates a stage 3 pressure ulcer specifically on the left lower back. Supporting documentation should detail the location, the depth of tissue involvement (full-thickness skin loss with visible subcutaneous fat), and the absence of exposed bone, tendon, or muscle.

• Always confirm the specific anatomical location (left lower back) and the documented stage (stage 3) to ensure accurate code assignment.
• Differentiate from unstageable pressure ulcers where the depth cannot be determined due to slough or eschar.
• Sequence this code as a secondary diagnosis when the pressure ulcer is a complication of another underlying condition.