Pressure ulcer of right buttock, stage 4

This code signifies a severe pressure injury located on the patient's right gluteal region. A stage 4 pressure ulcer involves full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone. Undermining and tunneling are often present.

Assign this code when documentation clearly indicates a stage 4 pressure ulcer specifically on the right buttock. This typically occurs in patients with prolonged immobility, such as those in long-term care, spinal cord injury patients, or post-surgical patients. Documentation should specify the location and the stage of the ulcer.

• Always confirm the specific anatomical site (right buttock) and the stage (stage 4) from the physician's documentation.
• Do not use this code for unstageable pressure ulcers or deep tissue pressure injuries (DTPIs); these have distinct codes.
• Sequence this code as a secondary diagnosis if the pressure ulcer is a comorbidity, or as a principal diagnosis if it is the primary reason for the encounter/admission.