Pressure ulcer of right upper back, stage 1
ICD-10 L89.111 is a billable code used to indicate a diagnosis of pressure ulcer of right upper back, stage 1.
L89.111 refers to a stage 1 pressure ulcer located on the right upper back. Clinically, a stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness of a localized area, typically over a bony prominence. The affected area may feel warmer or cooler compared to adjacent skin, and may present with changes in sensation, texture, or firmness. The anatomy involved includes the epidermis and dermis, where the pressure disrupts blood flow, leading to ischemia and potential tissue damage if not addressed promptly. Disease progression can lead to more severe stages of pressure ulcers if the underlying causes, such as immobility, inadequate nutrition, or moisture, are not managed. Diagnostic considerations include a thorough skin assessment, patient history, and risk factor evaluation using tools like the Braden Scale to determine the risk of pressure ulcer development. Early identification and intervention are crucial to prevent further deterioration.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
L89.111 specifically covers stage 1 pressure ulcers on the right upper back. It is important to note that this code is used when the ulcer is intact with non-blanchable erythema and does not extend into deeper layers of skin.
L89.111 should be used when documenting a stage 1 pressure ulcer specifically located on the right upper back. It is essential to differentiate it from other stages (L89.112 for stage 2, etc.) and other locations to ensure accurate coding.
Documentation should include a detailed description of the ulcer's characteristics, the location, stage, and any relevant patient history or risk factors. Photographic evidence and assessments using standardized tools can also support the diagnosis.
