Pressure ulcer of left heel, stage 4

This code signifies a severe pressure injury located on the left heel, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It often involves undermining and tunneling, indicating extensive tissue destruction.

Apply this code when documentation clearly specifies a stage 4 pressure ulcer on the patient's left heel. This diagnosis is typically supported by physical examination findings, wound care assessments, and photographic evidence detailing the depth and extent of tissue damage.

• Ensure the laterality (left heel) and the specific stage (stage 4) are explicitly documented.
• 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 when it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity being treated.