Pressure ulcer of unspecified buttock, unspecified stage

This code signifies a pressure injury located on the buttock, where the specific side (left or right) is not documented, and the severity or stage of the ulceration is also unknown. It indicates a localized area of tissue damage, typically over a bony prominence, resulting from sustained pressure.

Use this code when documentation clearly identifies a pressure ulcer on the buttock, but lacks specificity regarding laterality (e.g., "buttock pressure ulcer") and does not provide information about the ulcer's stage (e.g., "unstageable," "stage 2"). This code is appropriate for initial encounters or when complete staging information is unavailable.

• Avoid using this code if the laterality (left or right buttock) or the stage of the pressure ulcer is documented. Always strive for the most specific code available.
• Query the provider for clarification on laterality and stage if possible, as more specific codes offer better data for patient care and reimbursement.
• This code should be a last resort when documentation is truly ambiguous regarding both location specificity and stage.