Pressure ulcer of left buttock, unspecified stage

This code identifies a pressure injury located on the left gluteal region, where the specific severity or stage of tissue damage has not been documented. It indicates localized damage to the skin and underlying soft tissue, typically over a bony prominence, resulting from sustained pressure or pressure in combination with shear.

Apply this code when documentation clearly specifies a pressure ulcer on the left buttock but lacks information regarding the stage (e.g., Stage 1, 2, 3, 4, unstageable, or deep tissue injury). This is appropriate for initial assessments where staging is pending or when the stage cannot be determined due to eschar or slough.

• Always strive for documentation of the pressure ulcer stage; an unspecified stage should be a last resort.
• If the laterality is not specified, use the code for unspecified buttock.
• Do not use this code if the documentation indicates a specific stage, even if the stage is "unstageable" or "deep tissue injury," as those have their own specific codes.