Pressure ulcer of unspecified buttock, stage 1

This code signifies the earliest stage of a pressure injury located on an unspecified buttock. It presents as intact skin with a localized area of non-blanchable erythema, typically over a bony prominence, indicating persistent redness that does not turn white when pressed. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Apply this code when documentation clearly identifies a Stage 1 pressure ulcer on either the left or right buttock, but the specific side is not documented. This diagnosis is supported by findings of non-blanchable erythema on intact skin. It is frequently seen in patients with limited mobility or prolonged pressure.

• Ensure the documentation specifies "Stage 1" and "buttock" to accurately assign this code.
• Avoid using this code if the laterality (left or right buttock) is specified; instead, use the more specific L89.311 or L89.321.
• Do not use this code for deep tissue pressure injury (DTPI) or unstageable pressure ulcers, as those have distinct coding guidelines.