Non-pressure chronic ulcer of left ankle w fat layer exposed

This code signifies a persistent open sore on the left ankle that is not caused by pressure, with the ulceration extending through the skin and subcutaneous tissue to expose the underlying adipose tissue. It indicates a chronic wound that has penetrated beyond the dermis.

Apply this code for patients presenting with a long-standing ulcer on the left ankle where documentation clearly states the ulcer is non-pressure related and has reached the fat layer. Supporting documentation includes wound assessments noting depth, location, and chronicity, often in the context of vascular insufficiency, diabetes, or other systemic conditions.

• Ensure documentation specifies "left ankle" and "non-pressure" to differentiate from pressure ulcers or ulcers on other sites.
• Confirm the depth of the ulceration explicitly states or implies exposure of the fat layer; avoid using for superficial ulcers.
• Always code any underlying systemic conditions (e.g., diabetes, peripheral vascular disease) that contribute to the ulcer formation as primary or secondary diagnoses.