L89.102

HCC Category Mapping

What This Code Means

A stage 2 pressure ulcer on an unspecified area of the back involving partial-thickness skin loss, appearing as an open blister, abrasion, or shallow crater.

Coding Tips

• •Stage 2 involves partial-thickness skin loss affecting the epidermis and/or dermis; document whether the wound is open or presents as a blister
• •Ensure the ulcer is not deeper than stage 2; if full-thickness loss is present, code to stage 3 or 4 instead

Clinical Significance

A stage 2 pressure ulcer of the unspecified part of back represents Stage 2 pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, or an intact or open/ruptured serum-filled blister. Stage 2 does not include skin tears, tape burns, moisture-associated skin damage, or maceration. Pressure ulcers are significant indicators of patient frailty, immobility, and care complexity, requiring ongoing wound management and interdisciplinary care. Accurate staging and site documentation are essential for risk adjustment and quality reporting.

Documentation Requirements

• ✓Provider documentation of stage 2 pressure ulcer at the specific anatomic site
• ✓Description confirming partial-thickness skin loss
• ✓Wound bed description (red-pink, no slough or granulation tissue)
• ✓Wound measurements (length, width)
• ✓Current wound care treatment plan and any dressings used
• ✓Evidence the wound was evaluated during the encounter

Commonly Confused Codes