Pressure ulcer of left heel, unstageable

This code signifies a severe pressure injury located on the patient's left heel where the full extent of tissue damage cannot be determined due to the presence of slough or eschar. This indicates a deep tissue injury that is obscured, preventing accurate staging of the ulcer.

Apply this code when documentation clearly states a pressure ulcer on the left heel is "unstageable" due to non-removable slough or eschar. This diagnosis is appropriate when the depth of tissue loss cannot be visualized, even if underlying muscle, tendon, or bone might be involved.

• Ensure the documentation explicitly states "unstageable" and specifies the left heel as the anatomical site.
• Do not use this code if the ulcer is staged (e.g., Stage 1, 2, 3, 4, or deep tissue injury) or if the slough/eschar is removable.
• 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.