L89.114

HCC Category Mapping

What This Code Means

A stage 4 pressure sore on the right upper back involving full-thickness skin loss with exposure of underlying bone, tendon, or muscle.

Coding Tips

• •Stage 4 is the most severe, with full-thickness loss and visible deep structures; document all exposed anatomical structures
• •This stage often requires surgical intervention and has significant morbidity risk

Clinical Significance

A stage 4 pressure ulcer of the right upper back represents Stage 4 pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. These are the most severe pressure injuries and often extend into supporting structures with risk of osteomyelitis and sepsis. 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 4 pressure ulcer at the specific anatomic site
• ✓Description confirming exposed bone, tendon, or muscle
• ✓Wound measurements (length, width, depth) including undermining and tunneling
• ✓Wound bed characteristics and any necrotic tissue
• ✓Assessment for complications (osteomyelitis, sepsis, cellulitis)
• ✓Current wound care and surgical consultation if indicated
• ✓Evidence the wound was evaluated and actively managed during the encounter

Commonly Confused Codes