Pressure ulcer of right upper back, stage 3
ICD-10 L89.113 is a billable code used to indicate a diagnosis of pressure ulcer of right upper back, stage 3.
L89.113 refers to a stage 3 pressure ulcer located on the right upper back. Pressure ulcers, also known as bedsores or decubitus ulcers, occur when sustained pressure on the skin reduces blood flow to the area, leading to tissue damage. The right upper back is anatomically significant as it encompasses the skin and subcutaneous tissue overlying the scapula and upper thoracic spine. Clinically, a stage 3 pressure ulcer is characterized by full-thickness skin loss, which may extend into the subcutaneous tissue but not through underlying fascia. The ulcer may present with necrotic tissue, slough, or eschar, and may have a depth that varies based on the individual’s body habitus. Disease progression can occur if the ulcer is not properly managed, potentially leading to infection, further tissue loss, and complications such as osteomyelitis. Diagnostic considerations include a thorough assessment of the ulcer's size, depth, and surrounding skin condition, as well as evaluating the patient's overall health status and risk factors for pressure ulcer development, such as immobility, malnutrition, and comorbidities.
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
L89.113 specifically covers stage 3 pressure ulcers located on the right upper back, characterized by full-thickness skin loss. It does not cover ulcers at other stages or locations.
L89.113 should be used when documenting a stage 3 pressure ulcer on the right upper back, differentiating it from stage 1 or 2 ulcers, or ulcers located on other body parts.
Documentation should include a detailed assessment of the ulcer's size, depth, and characteristics, as well as the patient's risk factors and treatment plan. Photographic evidence may also be beneficial.
