Pressure ulcer of left lower back, stage 4

This code signifies a severe pressure injury located on the left lower back, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, or damage to supporting structures.

Apply this code when documentation clearly specifies a stage 4 pressure ulcer affecting the left lower back region. This typically involves deep tissue damage extending beyond the subcutaneous fat, often requiring complex wound care.

• Ensure the documentation explicitly states "stage 4" and specifies the "left lower back" as the anatomical site.
• Do not use this code for unstageable pressure ulcers or deep tissue injuries; distinct codes exist for those conditions.
• Always sequence this code after any underlying condition or cause of the pressure ulcer, if applicable.