Pressure ulcer of right heel, stage 2

This code signifies a pressure injury located on the right heel that involves partial-thickness skin loss, presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. It may also manifest as an intact or ruptured serum-filled blister.

Apply this code when documentation clearly indicates a stage 2 pressure ulcer specifically on the patient's right heel. This typically occurs in patients with limited mobility, prolonged bed rest, or impaired sensation. Supporting documentation should include the anatomical site, the stage of the ulcer, and a description consistent with partial-thickness skin loss.

• Ensure the laterality (right heel) is explicitly documented; do not assume.
• Verify the stage is clearly identified as "stage 2" and not an unstageable or deep tissue injury.
• Code any associated infections or complications separately.