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ICD-10 Guide
ICD-10 CodesL89.31

L89.31

Non-billable

Pressure ulcer of right buttock

BILLABLE STATUSNo
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 L89.31 is a used to indicate a diagnosis of pressure ulcer of right buttock.

Key Diagnostic Point:

L89.31 refers to a pressure ulcer located on the right buttock, a common condition that arises due to prolonged pressure on the skin, often in individuals with limited mobility. Clinically, pressure ulcers can present as localized areas of skin breakdown, which may progress through various stages from non-blanchable erythema to full-thickness tissue loss. The anatomy involved includes the skin and subcutaneous tissue, particularly over bony prominences where pressure is greatest. Disease progression can lead to serious complications, including infections, which may necessitate surgical intervention. Diagnostic considerations include a thorough assessment of the ulcer's stage, size, and any signs of infection, as well as evaluating the patient's overall health status and mobility. Accurate diagnosis is crucial for effective treatment planning and prevention strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires assessment of ulcer stage and potential comorbidities.
  • Treatment complexity: Involves multidisciplinary approaches including wound care, nutritional support, and possibly surgical intervention.
  • Documentation requirements: Detailed documentation of ulcer characteristics and treatment progress is essential.
  • Coding specificity: Specific to the location and stage of the ulcer, requiring precise coding.

Audit Risk Factors

  • Common coding errors: Misclassification of ulcer stage or location.
  • Documentation gaps: Incomplete records regarding ulcer assessment and treatment.
  • Billing challenges: Potential denials if documentation does not support the severity or treatment provided.

Specialty Focus

Medical Specialties

Primary medical specialty: Dermatology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Secondary specialty: Wound care management

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Pressure ulcers significantly impact patient quality of life and healthcare costs. They are associated with increased morbidity, prolonged hospital stays, and higher rates of readmission. Effective management and prevention of pressure ulcers are critical for improving patient outcomes and reducing healthcare utilization. Epidemiologically, pressure ulcers are prevalent in populations with limited mobility, such as the elderly and those with chronic illnesses, highlighting the need for targeted interventions.

ICD-9 vs ICD-10

Pressure ulcers significantly impact patient quality of life and healthcare costs. They are associated with increased morbidity, prolonged hospital stays, and higher rates of readmission. Effective management and prevention of pressure ulcers are critical for improving patient outcomes and reducing healthcare utilization. Epidemiologically, pressure ulcers are prevalent in populations with limited mobility, such as the elderly and those with chronic illnesses, highlighting the need for targeted interventions.

Reimbursement & Billing Impact

Reimbursement considerations include the severity of the ulcer and the complexity of care provided. Common denials may arise from insufficient documentation or failure to demonstrate medical necessity for treatments. Best practices include ensuring that all treatment plans, progress notes, and patient assessments are thoroughly documented and aligned with the coding submitted.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for L00-L99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for L00-L99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by L89.31?

L89.31 specifically covers pressure ulcers that occur on the right buttock, which may include various stages of ulceration from Stage I (non-blanchable erythema) to Stage IV (full-thickness tissue loss). It is important to document the stage and any associated complications.

When should L89.31 be used instead of related codes?

L89.31 should be used when the pressure ulcer is specifically located on the right buttock. If the ulcer is on a different location or if the location is unspecified, other codes such as L89.30 or L89.32 should be considered.

What documentation supports L89.31?

Documentation should include a detailed description of the ulcer's characteristics (size, depth, stage), the patient's mobility status, any comorbid conditions, and the treatment plan. Regular updates on the ulcer's progress are also necessary.