Pressure ulcer of unspecified buttock, stage 4

This code signifies a severe pressure injury located on an unspecified buttock, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It indicates extensive destruction, tissue necrosis, or damage to underlying structures.

Apply this code when documentation clearly identifies a stage 4 pressure ulcer on either the right or left buttock, and the specific side is not documented. This diagnosis requires evidence of deep tissue damage extending to bone, tendon, or muscle.

• Ensure the documentation explicitly states "stage 4" and specifies the buttock as the anatomical site.
• If the specific buttock (left or right) is documented, use the more specific codes L89.314 or L89.324.
• Always code any associated infections or complications, such as osteomyelitis, as secondary diagnoses.