N94.6 - Dysmenorrhea, unspecified

Clinical Definition

A non-pressure chronic ulcer of the back involves a localized area of tissue breakdown on the posterior trunk region that has persisted for 3 months or longer. Unlike pressure ulcers, these ulcers are not primarily caused by prolonged pressure but may result from other factors like vascular issues, diabetes, or trauma.

Documentation Requirements

• Chronicity must be noted (present > 3 months)

• Precise anatomical location on back

• Wound characteristics:

  • Depth/stage

  • Size measurements

  • Presence/absence of necrosis

  • Any exposed tissues (muscle/bone/tendon)

• Underlying cause or etiology

• Rule out pressure as primary cause

• Document any associated conditions (diabetes, vascular disease)

• Healing status (improving/deteriorating/stagnant)

Common Synonyms

• Open sore on back

• Non-healing wound

• Back wound

• Chronic wound

• Skin breakdown

Coding Conflicts

Excludes1:

• Pressure ulcer of back (L89.-)

• Decubitus ulcer

• Pressure-induced tissue damage

Excludes2:

• Acute ulcer of back

• Diabetic ulcers at other sites

Scribing.io Automation

The AI scribe automatically identifies and captures:

• Duration keywords ("chronic," "3+ months")

• Anatomical terms for back location

• Wound assessment terminology

• Measurements and staging descriptions

• Causative factors and exclusion of pressure

• Treatment plans and healing progress notes

These elements are structured into the appropriate documentation fields while maintaining context and clinical accuracy.