BETA v.3.0

2025 ICD-10-CM code L89.102

Pressure ulcer of unspecified part of the back, stage 2.

Accurate coding requires precise description of the stage and location of the pressure ulcer.Documentation must clearly support the assigned code.

Medical necessity for treatment of pressure ulcers is established by the presence of a wound that requires intervention to prevent infection, promote healing, and alleviate pain.The severity of the ulcer, the patient's overall health status, and the response to conservative treatment should be documented to justify the medical necessity of more intensive interventions.

Diagnosis and treatment of pressure ulcers are under the responsibility of dermatologists, wound care specialists, or primary care physicians. Treatment may involve wound care, pain management, and addressing underlying medical conditions.

IMPORTANT:Consider additional codes to specify location, laterality (right or left), and severity (stage).Also, code first any associated gangrene (I96).Excludes codes for decubitus ulcers of the cervix, diabetic ulcers, non-pressure chronic ulcers of the skin, and skin infections.

In simple words: This code describes a stage 2 pressure sore (bed sore) on the back.A stage 2 pressure sore is a wound that goes into the second layer of skin.

This code classifies a pressure ulcer located on an unspecified part of the back, specifically at stage 2.Stage 2 pressure ulcers involve partial thickness skin loss, with damage extending into the dermis.The ulcer may present as a shallow open ulcer or a ruptured serum-filled blister.

Example 1: A 70-year-old female patient with limited mobility develops a stage 2 pressure ulcer on her sacrum (lower back) after a prolonged period of bed rest following hip surgery., A 65-year-old male patient with paraplegia presents with a stage 2 pressure ulcer on his buttock, requiring regular wound care and pressure relief measures., An 80-year-old patient in a nursing home is found to have a stage 2 pressure ulcer on their upper back.A multidisciplinary approach involving wound care, physical therapy, and nutritional support is implemented.

Detailed documentation should include:* Patient's medical history and risk factors for pressure ulcers (e.g., immobility, malnutrition, incontinence).* Location, size, and depth of the ulcer.* Assessment of the wound bed (e.g., presence of necrotic tissue, exudate).* Description of surrounding skin.* Treatment plan and response to treatment.* Images of the ulcer (if available).

** This code is for a stage 2 pressure ulcer.Different stages of pressure ulcers have different codes.Always ensure proper documentation to support the assigned code.

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