Pressure ulcer of left buttock, stage 4

This code signifies a severe pressure injury located on the left gluteal region, characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. It often includes undermining and tunneling. This stage indicates extensive destruction and tissue necrosis.

Apply this code when documentation clearly specifies a pressure ulcer on the left buttock that has progressed to stage 4. Supporting documentation must detail the depth of tissue damage, including exposure of underlying structures like bone or muscle, and the specific anatomical location.

• Always confirm the specific anatomical site (left buttock) and the documented stage (stage 4) before assigning this code.
• Differentiate from unstageable pressure ulcers (L89.320) where the extent of tissue damage cannot be determined due to slough or eschar.
• Sequence this code as a primary diagnosis when the pressure ulcer is the reason for the encounter, or as a secondary diagnosis if it's a co-morbidity being managed.