Pressure ulcer of right heel, unspecified stage

This code signifies a pressure-induced localized injury to the skin and underlying tissue on the right heel. The specific severity or depth of tissue damage is not documented or cannot be determined.

Apply this code when documentation clearly identifies a pressure ulcer located on the patient's right heel, but the stage (e.g., Stage 1, Stage 2, unstageable) is not specified by the provider. This is appropriate when the provider's note simply states "pressure ulcer, right heel" without further detail on its severity.

• Always seek clarification from the provider if the stage of the pressure ulcer is missing, as a more specific code may be available.
• Do not use this code if any stage (e.g., Stage 1, Stage 2, unstageable) is documented; instead, select the appropriate stage-specific code.
• Remember to also code any associated complications, such as infection, if documented.