L89.112

HCC Category Mapping

What This Code Means

A stage 2 pressure sore on the right upper back involving partial thickness skin loss, appearing as a blister, abrasion, or shallow crater.

Coding Tips

• •Stage 2 involves partial-thickness skin loss affecting the epidermis and/or dermis; document if the wound bed is pink or red
• •Ensure documentation distinguishes stage 2 from stage 1 (which has intact skin) and stage 3 (which involves full-thickness loss)

Clinical Significance

A stage 2 pressure ulcer of the right upper 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