Pressure ulcer of right heel, stage 4

This code signifies a severe pressure injury located on the patient's right 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 the right heel. This typically involves a wound assessment by a physician or wound care specialist detailing the depth of tissue damage, presence of exposed structures, and location.

• Always confirm the specific anatomical site (right heel) and the documented stage (stage 4) before assigning.
• Do not use this code for unstageable pressure ulcers or deep tissue injuries; separate codes exist for those conditions.
• Sequence this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity being treated.