L97.115

HCC Category Mapping

What This Code Means

A long-lasting open sore on the right thigh that is not caused by pressure, where muscle tissue is involved but not dead.

Coding Tips

• •Distinguish this from L97.113 by confirming there is NO necrosis (tissue death) present
• •Document that muscle is involved in the ulcer but remains viable tissue

Clinical Significance

A non-pressure chronic ulcer of the right thigh with muscle involvement without evidence of necrosis represents a deep, non-healing wound involving structures beyond the subcutaneous tissue. These ulcers typically result from peripheral vascular disease, venous insufficiency, or other systemic conditions, and indicate significant tissue destruction requiring complex wound management. Deep non-pressure chronic ulcers map to V28 HCC 380 (Chronic Ulcer of Skin, Except Pressure) with a RAF of 0.426, reflecting the substantial clinical resources needed for management.

Documentation Requirements

• ✓Exact anatomical location with laterality (right, left, or bilateral thigh)
• ✓Etiology of the ulcer (venous insufficiency, peripheral arterial disease, neuropathic, post-traumatic, other)
• ✓Wound dimensions: length x width x depth in centimeters
• ✓Documentation of involved structures (muscle, bone, tendon) with or without necrosis
• ✓Wound bed description including percentage of granulation, slough, eschar, and necrotic tissue
• ✓Presence of undermining, tunneling, or sinus tracts with measurements
• ✓Vascular assessment results (ankle-brachial index, duplex ultrasound)
• ✓Current wound care plan including debridement method, dressing type, and frequency
• ✓Signs of infection (cellulitis, osteomyelitis, positive wound cultures)
• ✓Chronicity documentation — duration of wound and treatment history
• ✓Contributing comorbidities (diabetes mellitus, peripheral vascular disease, malnutrition)

Commonly Confused Codes