L89.113

HCC Category Mapping

What This Code Means

A stage 3 pressure sore on the right upper back involving full-thickness skin loss that may extend into the subcutaneous tissue but does not expose bone, tendon, or muscle.

Coding Tips

• •Stage 3 shows full-thickness skin loss with possible undermining or tunneling; document the depth and any drainage characteristics
• •Distinguish from stage 4 by confirming that bone, tendon, or muscle is not exposed

Clinical Significance

A stage 3 pressure ulcer of the right upper 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