Pressure ulcer of left buttock, stage 3

This code signifies a deep tissue injury on the left buttock caused by sustained pressure, characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue. The ulcer extends down to, but not through, the underlying fascia, presenting clinically as a deep crater.

Apply this code when documentation clearly indicates a pressure ulcer located on the patient's left buttock that has progressed to Stage 3. This stage is confirmed by visible subcutaneous fat, but bone, tendon, or muscle are not exposed.

• Ensure the documentation specifies "left buttock" and "stage 3" for accurate code assignment.
• Do not confuse with unstageable pressure ulcers where the depth cannot be determined due to slough or eschar.
• Always sequence this code after any underlying condition contributing to the pressure ulcer, such as immobility or malnutrition.