Pressure ulcer of sacral region, stage 4

This code represents a severe pressure injury located on the sacrum, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It often includes undermining and tunneling. This stage indicates extensive tissue damage and necrosis.

Use this code when documentation clearly identifies a sacral pressure ulcer that has progressed to Stage 4. This typically involves a wound assessment describing exposed deep tissues. Documentation should specify the anatomical location as the sacral region.

• Always confirm the specific anatomical site (sacral region) and the documented stage (Stage 4) from the physician's notes.
• Differentiate from unstageable pressure ulcers where the extent of tissue loss cannot be determined due to slough or eschar.
• Code any associated infections or complications separately.