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ICD-10 Guide
ICD-10 CodesL89.310

L89.310

Billable

Pressure ulcer of right buttock, unstageable

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

Code Description

ICD-10 L89.310 is a billable code used to indicate a diagnosis of pressure ulcer of right buttock, unstageable.

Key Diagnostic Point:

L89.310 refers to an unstageable pressure ulcer located on the right buttock. Pressure ulcers, also known as bedsores or decubitus ulcers, occur when sustained pressure on the skin restricts blood flow to the area, leading to tissue damage. The right buttock is anatomically significant as it is a common site for pressure ulcers, particularly in individuals with limited mobility or those who are bedridden. The unstageable designation indicates that the ulcer's depth cannot be determined due to the presence of necrotic tissue or eschar, making it challenging to assess the extent of tissue damage. Clinically, these ulcers may present with varying degrees of pain, redness, and swelling, and can progress to deeper tissue layers if not properly managed. Diagnostic considerations include a thorough patient history, physical examination, and potentially imaging studies to evaluate underlying structures. Effective management requires a multidisciplinary approach, including wound care, nutritional support, and pressure-relieving strategies to prevent further deterioration.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity
  • Treatment complexity
  • Documentation requirements
  • Coding specificity

Audit Risk Factors

  • Common coding errors include misclassification of ulcer stage or location.
  • Documentation gaps may arise if the depth of the ulcer is not clearly described.
  • Billing challenges can occur if the medical necessity for treatment is not adequately supported.

Specialty Focus

Medical Specialties

Wound Care

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

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

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The clinical significance of L89.310 lies in its association with increased morbidity and healthcare costs. Pressure ulcers can lead to severe complications, including infections and prolonged hospital stays, impacting population health. Quality measures often focus on the prevention and management of pressure ulcers, as they are indicators of healthcare quality. Understanding the epidemiology of pressure ulcers, particularly in vulnerable populations, can inform healthcare utilization patterns and guide preventive strategies.

ICD-9 vs ICD-10

The clinical significance of L89.310 lies in its association with increased morbidity and healthcare costs. Pressure ulcers can lead to severe complications, including infections and prolonged hospital stays, impacting population health. Quality measures often focus on the prevention and management of pressure ulcers, as they are indicators of healthcare quality. Understanding the epidemiology of pressure ulcers, particularly in vulnerable populations, can inform healthcare utilization patterns and guide preventive strategies.

Reimbursement & Billing Impact

Reimbursement considerations include verifying that the treatment provided is medically necessary and aligns with the documented severity of the ulcer. Common denials may arise from insufficient documentation or failure to demonstrate the need for advanced wound care. Best practices include maintaining thorough records of the patient's condition, treatment plans, and any consultations with specialists to support the billing process.

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 L89.310?

L89.310 covers unstageable pressure ulcers specifically located on the right buttock. This includes ulcers that cannot be staged due to the presence of slough or eschar, which obscures the wound bed.

When should L89.310 be used instead of related codes?

L89.310 should be used when the pressure ulcer is specifically located on the right buttock and is unstageable. If the ulcer is on a different anatomical site or is stageable, other codes should be selected.

What documentation supports L89.310?

Documentation should include a detailed description of the ulcer's location, appearance, and any associated symptoms. Clinical notes should also reflect the assessment of the ulcer's depth and any treatment plans implemented.