Pressure ulcer of unspecified heel, stage 1

This code signifies the earliest stage of a pressure injury affecting an unspecified heel. It presents as intact skin with non-blanchable redness, typically in a localized area, indicating potential tissue damage. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Apply this code when documentation specifies a Stage 1 pressure ulcer on a heel, but the laterality (left or right) is not explicitly stated. This diagnosis is supported by nursing assessments, wound care notes, or physician documentation describing the characteristic non-blanchable erythema on intact skin.

• Ensure the documentation clearly states "Stage 1" and "heel" to avoid miscoding.
• Do not use this code if the laterality (left or right heel) is specified; use the more specific L89.611 or L89.621.
• This code should not be used for deep tissue injury (DTI) or unstageable pressure ulcers, which have distinct ICD-10-CM codes.