L89.122
BillablePressure ulcer of left upper back, stage 2
HCC Category Mapping
V28HCC 382 — Pressure Ulcer of Skin with Partial Thickness Skin Loss
0.000V24HCC 159 — Pressure Ulcer of Skin with Partial Thickness Skin Loss
0.000ESRDHCC 159 — Pressure Ulcer of Skin with Partial Thickness Skin Loss
0.000What This Code Means
A stage 2 pressure sore on the left 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
Stage 2 pressure ulcers of the left upper back represent partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a shallow open ulcer or intact/ruptured blister. While less severe than deeper stages, they signal early pressure injury that requires prompt intervention to prevent progression. Accurate staging and documentation are critical for appropriate resource allocation and care planning.
Documentation Requirements
- ✓Exact anatomical location specified as left upper back
- ✓Stage explicitly documented as stage 2 by the provider
- ✓Description of wound appearance (blister, abrasion, shallow crater, pink/red wound bed)
- ✓Wound measurements (length x width in centimeters)
- ✓Presence or absence of drainage and its characteristics
- ✓Surrounding skin condition (erythema, induration, maceration)
- ✓Contributing risk factors (immobility, incontinence, malnutrition)
- ✓Treatment and repositioning plan
Commonly Confused Codes
L89.121 — Stage 1 left upper back; use when skin is intact with non-blanchable erythema onlyL89.123 — Stage 3 left upper back; use when full-thickness skin loss extends into subcutaneous tissueL89.112 — Stage 2 right upper back; laterality differenceL89.120 — Unstageable left upper back; use when wound cannot be staged due to eschar/slough
Code Hierarchy
└L89Pressure ulcer└L89.1Pressure ulcer of back└L89.12Pressure ulcer of left upper back└L89.122Pressure ulcer of left upper back, stage 2
└L89.122Pressure ulcer of left upper back, stage 2