Pressure ulcer of unspecified buttock, stage 4
ICD-10 L89.304 is a billable code used to indicate a diagnosis of pressure ulcer of unspecified buttock, stage 4.
Pressure ulcers, also known as bedsores or decubitus ulcers, are localized injuries to the skin and underlying tissue, primarily caused by prolonged pressure, often in patients with limited mobility. A stage 4 pressure ulcer is characterized by full-thickness tissue loss, exposing muscle, bone, or supporting structures such as tendons or joints. In the case of an unspecified buttock, the ulcer may present as a deep crater with necrotic tissue and may also involve tunneling or undermining. The anatomy involved includes the skin layers (epidermis, dermis) and subcutaneous tissue, with potential involvement of deeper structures. Disease progression can lead to severe complications, including infections, sepsis, and increased morbidity. Diagnostic considerations include a thorough clinical assessment, staging of the ulcer, and evaluation of the patient's overall health status, including comorbidities that may affect healing, such as diabetes or vascular disease. Regular monitoring and reassessment are crucial for effective management and treatment planning.
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
L89.304 specifically covers stage 4 pressure ulcers located on the unspecified buttock. It is critical to differentiate this from other stages of pressure ulcers and other skin conditions that may present similarly.
L89.304 should be used when documenting a stage 4 pressure ulcer on the buttock, particularly when the ulcer is deep and involves underlying structures. It is important to use this code when the specific location is not documented.
Documentation must include a detailed description of the ulcer's characteristics, staging, assessment of surrounding skin, patient mobility status, and any comorbid conditions that may impact healing.
