Pressure ulcer of right ankle, stage 1

This code signifies a pressure ulcer located on the right ankle that presents as intact skin with non-blanchable redness, indicating a Stage 1 injury. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. This is the earliest stage of pressure injury development.

Apply this code when documentation clearly identifies a pressure ulcer on the patient's right ankle and specifies it as Stage 1. This typically occurs during initial assessment or follow-up when the ulcer is superficial and has not progressed to tissue loss. Supporting documentation should include the anatomical site, laterality, and the stage of the pressure ulcer.

• Ensure the documentation explicitly states "right ankle" and "Stage 1."
• Do not use this code if there is any break in the skin or tissue loss; refer to higher stages.
• Always sequence this code after any underlying condition causing the pressure ulcer (e.g., immobility, diabetes with neuropathy).