Pressure ulcer of right ankle, stage 4

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

Apply this code when documentation clearly states a pressure ulcer (also known as pressure sore, decubitus ulcer, or bed sore) on the patient's right ankle has progressed to stage 4. Supporting documentation must detail the extent of tissue damage, including visible bone, tendon, or muscle.

• Always confirm the specific anatomical site (right ankle) and the documented stage (stage 4) before assigning this code.
• Distinguish from other stages of pressure ulcers; stage 4 implies exposed deep tissues, not just full-thickness skin loss.
• Proper sequencing requires coding any associated complications, such as osteomyelitis, after the pressure ulcer code.