Pressure ulcer of head, stage 4

This code signifies a severe pressure injury located on the patient's head, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Apply this code when documentation clearly states a Stage 4 pressure ulcer on any part of the head (e.g., occiput, temporal region). This diagnosis is supported by physician notes describing exposed bone, tendon, or muscle within the wound bed.

• Always confirm the specific anatomical location (head) and the documented stage (Stage 4) from the provider's notes.
• Do not use this code for unstageable pressure ulcers or deep tissue pressure injuries; specific codes exist for those.
• Sequence this code after any underlying condition that led to the pressure ulcer, if applicable.