Open wound of buttock, complicated

This code signifies an open wound located on the buttock that has experienced complications such as delayed healing, foreign body retention, or infection. It indicates a break in the skin integrity in the gluteal region, which is not healing as expected or has additional adverse factors.

Use this code for traumatic open wounds of the buttock that present with complications. Documentation should clearly specify the location as the buttock and detail the complicating factor, such as evidence of infection (e.g., purulent drainage, erythema, fever), presence of a foreign body, or significant tissue loss requiring complex closure.

• Differentiate from uncomplicated open wounds of the buttock, which would be coded differently.
• Ensure documentation explicitly states "complicated" or describes the specific complication present.
• Consider sequencing with external cause codes (E-codes) to describe the circumstances of the injury.