Pressure ulcer of left buttock, unstageable

This diagnosis code signifies a severe pressure injury located on the left gluteal region where the full extent of tissue damage cannot be determined due to obscuring slough or eschar. The depth of the ulcer, whether partial or full-thickness, is unknown until debridement or slough/eschar removal.

Apply this code when documentation clearly indicates a pressure ulcer on the left buttock with necrotic tissue (slough or eschar) that covers the wound bed, preventing accurate staging. This is typically used when the provider explicitly states "unstageable" or describes the wound characteristics consistent with an unstageable pressure injury.

• Ensure the documentation specifies "left buttock" and "unstageable" or describes the wound as having full coverage of slough/eschar.
• Do not use this code if the wound bed is visible and a stage (e.g., stage 3, stage 4) can be determined.
• Sequence this code after any underlying medical conditions contributing to the pressure ulcer, such as immobility or malnutrition.