L89.110
BillablePressure ulcer of right upper back, unstageable
HCC Category Mapping
V28HCC 381 — Pressure Ulcer of Skin, Unstageable/Unspecified
0.000V24HCC 158 — Pressure Ulcer of Skin with Full Thickness Skin Loss
0.662ESRDHCC 158 — Pressure Ulcer of Skin with Full Thickness Skin Loss
0.000What This Code Means
A pressure sore on the right upper back that cannot be classified into a specific stage due to the presence of slough or eschar covering the wound.
Coding Tips
- •Use this code when the pressure ulcer stage cannot be determined because necrotic tissue obscures the wound depth
- •Do not assign a stage code if the ulcer is unstageable; these are mutually exclusive
Clinical Significance
A unstageable pressure ulcer of the right upper back represents Unstageable pressure ulcers have full-thickness tissue loss where the base is covered by slough and/or eschar, preventing accurate staging. This category also includes deep tissue pressure injuries. 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 unstageable pressure ulcer at the specific anatomic site
- ✓Description of wound base (covered by slough, eschar, or deep tissue injury features)
- ✓Explanation of why the ulcer cannot be staged (wound base obscured)
- ✓Wound dimensions (length, width, depth if measurable)
- ✓Current wound care treatment plan
- ✓Evidence the wound was evaluated and managed during the encounter
Commonly Confused Codes
L89.113 (Pressure ulcer of right upper back, stage 3) — use when wound base is visible and full-thickness loss is confirmed without bone/tendon exposureL89.114 (Pressure ulcer of right upper back, stage 4) — use when wound base is visible and bone/tendon/muscle is exposedL89.x (Pressure ulcer at other sites) — verify the correct anatomic location
Code Hierarchy
└L89Pressure ulcer└L89.1Pressure ulcer of back└L89.11Pressure ulcer of right upper back└L89.110Pressure ulcer of right upper back, unstageable
└L89.110Pressure ulcer of right upper back, unstageable