Pressure ulcer of unspecified heel, stage 4
ICD-10 L89.604 is a billable code used to indicate a diagnosis of pressure ulcer of unspecified heel, stage 4.
Pressure ulcers, also known as bedsores or decubitus ulcers, are localized injuries to the skin and underlying tissue, primarily caused by prolonged pressure, often over bony prominences. The heel is a common site for these ulcers due to its anatomical structure and the pressure exerted when a patient is immobile. Stage 4 pressure ulcers are characterized by full-thickness tissue loss, exposing muscle, bone, or supporting structures such as tendons or joints. Clinical presentation includes a deep wound that may have necrotic tissue and is often accompanied by infection, which can complicate healing. Disease progression can lead to severe complications, including systemic infections and sepsis if not managed appropriately. Diagnostic considerations involve a thorough clinical assessment, including the evaluation of the ulcer's size, depth, and any signs of infection. Healthcare providers must also assess the patient's overall health status, mobility, and nutritional needs to develop an effective treatment plan.
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
L89.604 specifically covers stage 4 pressure ulcers located on the heel, which involve full-thickness skin loss and may expose underlying structures. It is crucial to differentiate this from other stages of pressure ulcers and other skin conditions.
L89.604 should be used when documenting a stage 4 pressure ulcer on the heel, particularly when there is evidence of full-thickness tissue loss. It should not be used for stage 1, 2, or 3 ulcers or for ulcers located on other body parts.
Documentation must include a detailed description of the ulcer's characteristics, stage, location, and any associated complications. Clinical assessments, treatment plans, and progress notes are essential to substantiate the use of this code.
