Pressure ulcer of sacral region, stage 2
ICD-10 L89.152 is a billable code used to indicate a diagnosis of pressure ulcer of sacral region, stage 2.
L89.152 refers to a stage 2 pressure ulcer located in the sacral region, characterized by partial thickness loss of skin involving the epidermis and/or dermis. Clinically, this ulcer may present as a shallow open sore with a red or pink wound bed, without slough or necrosis. The sacral region, which includes the lower back just above the tailbone, is particularly susceptible to pressure ulcers due to prolonged pressure, friction, or shear forces, especially in individuals with limited mobility or those who are bedridden. Disease progression can lead to deeper tissue damage if not properly managed, potentially advancing to stage 3 or 4 ulcers. Diagnostic considerations include a thorough clinical assessment of the ulcer's characteristics, patient history, and risk factors such as immobility, malnutrition, and comorbid conditions. Accurate staging is crucial for appropriate treatment planning and monitoring of healing progress.
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
L89.152 specifically covers stage 2 pressure ulcers in the sacral region, which are characterized by partial thickness skin loss. It does not cover ulcers that are deeper (stage 3 or 4) or those located in other anatomical regions.
L89.152 should be used when documenting a stage 2 pressure ulcer specifically located in the sacral area. It is important to differentiate it from other codes that represent different stages or locations of pressure ulcers.
Documentation should include a detailed assessment of the ulcer's characteristics, staging, treatment plan, and any underlying risk factors. Photographic evidence and regular updates on healing progress can also support the use of this code.
