Pressure ulcer of right heel, stage 4
ICD-10 L89.614 is a billable code used to indicate a diagnosis of pressure ulcer of right 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. The right 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, and may include necrosis of surrounding tissue. Clinically, these ulcers present with significant pain, potential for infection, and can lead to serious complications such as sepsis. The disease progression typically begins with non-blanchable erythema, advancing through stages of partial and full-thickness skin loss. Diagnostic considerations include a thorough clinical examination, assessment of the ulcer's depth, and evaluation of surrounding tissue integrity. Proper staging is crucial for treatment planning and prognosis, as stage 4 ulcers require advanced interventions, including surgical debridement and possibly reconstructive surgery.
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
L89.614 specifically covers stage 4 pressure ulcers located on the right heel, characterized by full-thickness skin loss and exposure of underlying structures. It does not cover ulcers at other sites or those at different stages.
L89.614 should be used when documenting a stage 4 pressure ulcer on the right heel, particularly when there is evidence of extensive tissue damage. It is essential to differentiate it from stage 3 ulcers (L89.613) and other locations to ensure accurate coding and appropriate reimbursement.
Documentation must include a detailed assessment of the ulcer's size, depth, and stage, along with treatment plans and patient progress notes. Photographic evidence and descriptions of surrounding tissue condition can enhance documentation quality.
