L89.103

HCC Category Mapping

What This Code Means

A stage 3 pressure ulcer on an unspecified area of the back with full-thickness skin loss extending into the subcutaneous tissue, appearing as a deep crater that may undermine surrounding skin.

Coding Tips

• •Stage 3 involves full-thickness skin loss but does not expose muscle, bone, or tendon; document depth and any undermining or tunneling
• •Clarify that bone or muscle is not visible; if exposed, this would be stage 4

Clinical Significance

A stage 3 pressure ulcer of the unspecified part of back represents Stage 3 pressure ulcers involve full-thickness tissue loss with subcutaneous fat visible but no exposure of bone, tendon, or muscle. Slough may be present but does not obscure the depth of tissue loss. The depth varies by anatomic location — shallow in areas without subcutaneous tissue. 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 3 pressure ulcer at the specific anatomic site
• ✓Description confirming full-thickness skin loss with visible subcutaneous fat
• ✓Confirmation that bone, tendon, or muscle is NOT visible or palpable
• ✓Wound measurements (length, width, depth) and any undermining or tunneling
• ✓Wound bed characteristics (granulation, slough, necrosis)
• ✓Current wound care treatment plan including debridement if indicated
• ✓Evidence the wound was evaluated and managed during the encounter

Commonly Confused Codes