Pressure-induced deep tissue damage of right buttock

This code signifies a pressure injury affecting the deep tissues of the right buttock, where the full extent of tissue damage beneath the skin is not initially visible. It indicates a severe form of pressure ulcer, often presenting as a purple or maroon localized area of discolored intact skin or a blood-filled blister. This damage results from prolonged pressure and/or shear forces.

Apply this code when documentation explicitly states "deep tissue injury," "deep tissue damage," or "suspected deep tissue injury" of the right buttock due to pressure. This diagnosis is typically made when the underlying muscle or subcutaneous tissue is compromised, even if the skin surface appears intact or only mildly discolored. Supporting documentation should include the location (right buttock) and the nature of the injury.

• Do not use this code for unstageable pressure ulcers where the depth is obscured by slough or eschar; those have distinct codes.
• Ensure documentation clearly specifies "deep tissue" and the exact anatomical site (right buttock) to avoid miscoding.
• This code is for the initial diagnosis of deep tissue damage; subsequent encounters for the same injury would typically use a different code reflecting the progression or healing stage once the full depth is ascertainable.