Pressure ulcer of head, stage 2

This code describes a partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough, or as an intact or ruptured serum-filled blister, located on the head. It indicates damage to the skin and underlying tissue due to prolonged pressure, friction, or shear.

Use this code when documentation clearly indicates a pressure ulcer on the patient's head that has progressed to Stage 2. This typically involves a visible blister or shallow open sore, and the medical record should specify the anatomical location as the head.

• Always confirm the specific anatomical location (head) and the documented stage (Stage 2) from the physician's notes.
• Differentiate from other skin lesions such as excoriations, skin tears, or dermatitis, which are not pressure ulcers.
• Sequence this code as a secondary diagnosis following the primary reason for the encounter, unless the pressure ulcer is the primary reason for admission or treatment.