Pressure ulcer of left buttock, stage 2

This code signifies a partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough, or as an intact or ruptured serum-filled blister, located on the patient's left gluteal region. It indicates damage to the skin and underlying tissue due to prolonged pressure, shear, or friction.

Use this code when documentation clearly identifies a pressure ulcer on the left buttock that meets the clinical criteria for Stage 2. This typically involves a visible ulcer or blister. Supporting documentation includes wound assessments, nursing notes, physician orders, and photographic evidence detailing location, size, and stage.

• Ensure the documentation explicitly states "left buttock" and "Stage 2." Avoid using this code if the stage is not clearly defined or is different.
• Differentiate from unstageable pressure ulcers (L89.9xx) or deep tissue injury (L89.xxx9) which have distinct clinical presentations.
• Always code the highest stage documented if a pressure ulcer progresses through stages during an encounter.