Pressure ulcer of right buttock, stage 3

This code identifies a full-thickness skin and tissue loss involving the right gluteal region, where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. It signifies a significant pressure injury characterized by deep crater formation, potentially with undermining or tunneling.

Apply this code when documentation explicitly states a Stage 3 pressure ulcer located on the patient's right buttock. Supporting documentation should detail the depth of tissue loss, the presence of subcutaneous fat, and the absence of exposed bone or muscle.

• Always confirm the specific anatomical site (right buttock) and the exact stage (Stage 3) from the provider's documentation.
• Do not confuse Stage 3 with unstageable pressure ulcers, which involve obscured depth due to slough or eschar.
• Sequence this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity.