Pressure ulcer of head, unstageable

This code signifies a pressure injury located on the head that cannot be accurately staged due to obscuring factors. This typically means the full extent of tissue damage, such as depth, is not visible because of slough or eschar. It indicates a severe pressure ulcer where the base of the wound is not discernible.

Apply this code when documentation specifies a pressure ulcer on the head and explicitly states it is "unstageable." This often occurs when the wound bed is covered by non-viable tissue (e.g., thick eschar or extensive slough) that prevents assessment of the true tissue loss depth. The physician's assessment must clearly indicate the unstageable nature.

• Ensure the documentation explicitly states "unstageable" for the pressure ulcer on the head; do not assume unstageable based on descriptions of slough or eschar alone.
• Do not code an unstageable pressure ulcer if debridement has revealed a stageable wound; in such cases, code the appropriate stage.
• This code takes precedence over other staging codes for the same ulcer if it is truly unstageable.