Pressure ulcer of sacral region, stage 2

This code signifies a partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough, or as an intact or ruptured serum-filled blister, located on the sacral region. It indicates damage to the skin and underlying tissue due to prolonged pressure, friction, or shear.

Apply this code when documentation clearly identifies a pressure ulcer on the sacrum that meets the criteria for a Stage 2 classification. This typically involves a visible break in the skin or a blister. Supporting documentation includes physician notes, wound care assessments, and nursing records detailing the location, size, and characteristics of the ulcer.

• Ensure the documentation explicitly states "sacral region" and "stage 2" for accurate code assignment.
• Differentiate from other sacral skin conditions like dermatitis or excoriation; this code is specifically for pressure-induced tissue damage.
• Always code the highest stage documented if a pressure ulcer progresses and then heals to a lower stage during the same encounter.