Pressure ulcer of right buttock, stage 2
ICD-10 L89.312 is a billable code used to indicate a diagnosis of pressure ulcer of right buttock, stage 2.
L89.312 refers to a stage 2 pressure ulcer located on the right buttock. Clinically, a stage 2 pressure ulcer is characterized by partial-thickness loss of skin, which may present as a shallow open ulcer with a red-pink wound bed, without slough. The ulcer may also present as an intact or ruptured serum-filled blister. The anatomy involved primarily includes the skin and subcutaneous tissue overlying the ischial tuberosity, which is particularly susceptible to pressure due to prolonged immobility or friction. Disease progression can occur if the pressure is not relieved, potentially advancing to stage 3 or 4 ulcers, which involve deeper tissue damage. Diagnostic considerations include a thorough clinical assessment of the ulcer's characteristics, patient history, and risk factors such as immobility, nutritional status, and comorbidities. Proper staging is essential for treatment planning and monitoring healing progress.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
L89.312 specifically covers stage 2 pressure ulcers located on the right buttock. It is important to differentiate this from other stages of pressure ulcers and other skin lesions that may appear similar.
L89.312 should be used when documenting a stage 2 pressure ulcer on the right buttock. It is crucial to use this code when the ulcer is confirmed to be at this stage, as using a different code could misrepresent the severity of the condition.
Documentation should include a detailed description of the ulcer's characteristics, staging, location, and any relevant patient history, including risk factors and treatment plans. Photographic evidence may also be beneficial.
