Pressure ulcer of right heel, unstageable

This code signifies a severe pressure injury located on the right heel where the full extent of tissue damage cannot be determined. This typically occurs due to the presence of slough or eschar that obscures the wound bed, preventing accurate staging. The underlying tissue damage may involve muscle, bone, or other structures.

Apply this code when documentation explicitly states a pressure ulcer on the right heel is "unstageable" due to obscuring necrotic tissue. This diagnosis is appropriate when debridement is required before a definitive stage can be assigned. Supporting documentation must clearly indicate the anatomical location and the inability to stage.

• Ensure documentation specifies "right heel" and "unstageable" to accurately assign this code.
• Do not use this code if the wound bed is visible and a stage can be determined, even if it's a deep tissue injury.
• Sequence this code as a primary diagnosis when it is the focus of treatment, or as a secondary diagnosis if another condition is the primary reason for the encounter.