Pressure ulcer of right upper back, stage 2
ICD-10 L89.112 is a billable code used to indicate a diagnosis of pressure ulcer of right upper back, stage 2.
L89.112 refers to a stage 2 pressure ulcer located on the right upper back. Clinically, a stage 2 pressure ulcer is characterized by partial thickness loss of skin, which may present as an abrasion, blister, or shallow crater. The ulcer involves the epidermis and may extend into the dermis but does not penetrate through the full thickness of the skin. The right upper back is anatomically significant as it is a common site for pressure ulcers, particularly in patients who are immobile or have limited mobility. Disease progression can occur if the ulcer is not properly managed, potentially leading to deeper tissue damage (stage 3 or 4 ulcers) or systemic infections. Diagnostic considerations include a thorough assessment of the ulcer's depth, size, and surrounding tissue condition, as well as evaluating the patient's overall health status and risk factors such as immobility, malnutrition, and comorbidities. Regular monitoring and appropriate interventions are essential for healing and preventing complications.
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
L89.112 specifically covers stage 2 pressure ulcers located on the right upper back. It is important to differentiate this from other stages of pressure ulcers and other skin conditions that may present similarly.
L89.112 should be used when documenting a stage 2 pressure ulcer on the right upper back. It is essential to use this code when the ulcer is confirmed to be at this stage and location, as other codes may refer to different stages or locations.
Documentation should include a detailed description of the ulcer's characteristics, including size, depth, and any exudate. Additionally, the patient's risk factors and the treatment plan should be documented to support the diagnosis.
