Pressure ulcer of unspecified heel, stage 2

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

Use this code when documentation clearly identifies a stage 2 pressure ulcer located on either the left or right heel, but the specific side is not documented. This is appropriate for patients presenting with a newly diagnosed or existing stage 2 pressure injury to the heel where laterality is unknown.

• Ensure the documentation explicitly states "stage 2" and "heel" to support this code.
• Avoid using this code if the laterality (left or right heel) is specified; instead, use the more specific L89.612 or L89.622.
• Do not use for unstageable pressure ulcers or deep tissue pressure injuries; these have distinct codes.