Pressure ulcer of unspecified heel, unspecified stage

This code signifies a pressure-induced skin and tissue injury located on an unspecified heel, where the specific stage of the ulceration has not been documented by the provider. It indicates the presence of a pressure ulcer without further detail regarding its severity or depth.

Use this code when documentation confirms a pressure ulcer on either the left or right heel, but the medical record lacks information about the ulcer's stage (e.g., Stage 1, Stage 2, etc.). This is typically an interim code used when awaiting further assessment or when the stage cannot be determined.

• Avoid using this code if the laterality (left/right heel) or the stage of the pressure ulcer is documented; more specific codes exist.
• Always query the provider for clarification on laterality and stage to allow for more precise coding.
• This code should be a last resort when all efforts to obtain more specific documentation have failed.