Pressure ulcer of unspecified heel, stage 4

This code signifies a severe pressure injury located on an unspecified heel, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, and often includes undermining and tunneling.

Apply this code when documentation clearly states a stage 4 pressure ulcer on either the right or left heel, without further specification of the side. This diagnosis is supported by findings of exposed deep tissues such as bone, tendon, or muscle within the ulcer bed.

• Always confirm the specific anatomical site (heel) and the documented stage (4) from the physician's notes.
• Do not use this code if the laterality (right or left heel) is specified; instead, select the more specific code.
• Code any associated infections or complications, such as osteomyelitis, as additional diagnoses.