L89.124

Billable

Pressure ulcer of left upper back, stage 4

HCC Category Mapping

V28HCC 379 — Pressure Ulcer of Skin with Full Thickness Skin Loss

0.662

V24HCC 157 — Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

1.071

ESRDHCC 157 — Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

0.000

What This Code Means

A stage 4 pressure ulcer (bedsore) on the left upper back that extends through all skin layers and involves muscle, bone, or supporting structures.

Coding Tips

•Stage 4 is the most severe; ensure documentation confirms involvement of deeper structures like muscle or bone
•This stage typically requires intensive wound care and may indicate higher risk for complications

Clinical Significance

Stage 4 pressure ulcers of the left upper back are the most severe classification, involving full-thickness tissue loss with exposed bone, tendon, muscle, or joint capsule. These represent life-threatening wounds with high complication rates including osteomyelitis and sepsis. They carry the highest risk adjustment weight among pressure ulcer codes, reflecting the extraordinary clinical complexity and resource utilization required for management.

Documentation Requirements

✓Exact anatomical location specified as left upper back
✓Stage explicitly documented as stage 4 by the provider
✓Identification of exposed deep structures (bone, muscle, tendon, joint capsule)
✓Wound dimensions (length x width x depth in centimeters)
✓Presence and extent of undermining or tunneling with directional documentation
✓Wound bed characteristics including percentage of necrotic tissue, slough, and granulation
✓Evidence of complications (osteomyelitis, cellulitis, sepsis, abscess)
✓Drainage characteristics and volume
✓Nutritional status and albumin/prealbumin levels
✓Comprehensive wound care plan including debridement schedule and wound VAC if applicable

Commonly Confused Codes

L89.123 — Stage 3 left upper back; use when subcutaneous tissue is involved but bone/muscle is NOT exposed L89.120 — Unstageable left upper back; use when wound bed cannot be assessed due to eschar/slough L89.114 — Stage 4 right upper back; laterality difference L89.144 — Stage 4 left lower back; different anatomical subsite

Code Hierarchy

└L89Pressure ulcer └L89.1Pressure ulcer of back └L89.12Pressure ulcer of left upper back └L89.124Pressure ulcer of left upper back, stage 4

└L89.124Pressure ulcer of left upper back, stage 4