Pressure ulcer of right buttock, stage 1

This code identifies an area of non-blanchable erythema on the right buttock, indicating the earliest stage of skin breakdown due to sustained pressure. The skin is intact, but a localized area of persistent redness is present, often accompanied by changes in skin temperature, consistency, or sensation compared to adjacent tissue.

Apply this code when documentation clearly states a Stage 1 pressure ulcer located specifically on the right buttock. This typically occurs in bedridden or immobile patients, or those with compromised sensation, where sustained pressure has led to initial tissue damage. The physician's assessment must confirm the stage and anatomical site.

• Ensure the documentation specifies "right buttock" and "stage 1." Laterality is crucial.
• Do not use for deep tissue injury (DTI) or unstageable ulcers; these have distinct codes.
• Always sequence the pressure ulcer code after any underlying condition causing immobility, if applicable.