L89.122 Pressure ulcer of left upper back, stage 2

ICD10CM code

#### Name of the Condition
- Pressure ulcer of left upper back, stage 2
- Also known as: Stage 2 pressure sore, decubitus ulcer

#### Summary
- A stage 2 pressure ulcer is an open wound that occurs when there is prolonged pressure on the skin, often affecting bony areas like the upper back. In this stage, the skin breaks open, forming a shallow ulcer or blister, which can become painful and expose deeper skin layers.

#### Causes
- Prolonged pressure on the skin reduces blood flow, causing tissue damage. It often occurs in bedridden or immobile patients who cannot change position frequently.

#### Risk Factors
- Limited mobility, advanced age, dehydration, poor nutrition, and certain conditions such as diabetes or vascular disease increase the risk of developing pressure ulcers.

#### Symptoms
- Redness, blistering, or open sores on the left upper back, with possible pain or tenderness.

#### Diagnosis
- Physical examination by a healthcare professional is the primary method to diagnose a stage 2 pressure ulcer, assessing wound depth and the area affected.

#### Treatment Options
- Wound cleaning and dressing to promote healing and prevent infection. 
- Pressure relief via repositioning or using supportive surfaces like specialized mattresses or cushions.
- Topical or oral antibiotics if infection is present.

#### Prognosis and Follow-Up
- With proper care, stage 2 pressure ulcers often heal within weeks. Regular monitoring and preventive care are critical to avoid progression to more severe stages.

#### Complications
- Untreated ulcers can lead to infections, chronic wounds, or progression to more severe stages, which are harder to treat.

#### Lifestyle & Prevention
- Regularly change positions to relieve pressure, maintain good nutrition, and keep the skin clean and dry.
- Use supportive devices like padded cushions and mattresses.

#### When to Seek Professional Help
- Seek medical attention if you notice signs of infection (redness, pus, increased pain) or if the ulcer does not improve with basic care.

#### Additional Resources
- National Pressure Ulcer Advisory Panel (NPUAP): [npuap.org](https://www.npuap.org)
- Wound, Ostomy and Continence Nurses Society (WOCN): [wocn.org](https://www.wocn.org)

#### Tips for Medical Coders
- Ensure the correct anatomic location and stage are documented: left upper back, stage 2.
- Verify the completeness of documentation to avoid errors in coding and ensure accurate billing.

Medical Policies and Guidelines for Pressure ulcer of left upper back, stage 2

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