Pressure-induced deep tissue damage of unspecified heel

This code signifies a severe form of pressure injury characterized by persistent non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister, indicating damage to the underlying soft tissue from pressure and/or shear. The skin may be intact or non-intact, but the deep tissue damage is suspected beneath the surface. This specific code identifies such an injury located on an unspecified heel.

Utilize this code when documentation clearly indicates a suspected deep tissue injury (sDTI) on a patient's heel, where the specific laterality (left or right) is not documented. This diagnosis is typically made based on clinical assessment of skin changes and patient history of pressure. Documentation should describe the characteristic discoloration or blister and the location.

• Do not use this code if the laterality of the heel is specified; instead, use the more specific L89.616 or L89.626.
• This code represents a suspected deep tissue injury, not an unstageable pressure ulcer.
• Always review the entire medical record to ensure the most specific and accurate code is selected.