Pressure ulcer of contiguous site of back, buttock and hip, stage 4
ICD-10 L89.44 is a billable code used to indicate a diagnosis of pressure ulcer of contiguous site of back, buttock and hip, stage 4.
L89.44 refers to a stage 4 pressure ulcer located on contiguous sites of the back, buttock, and hip. Clinically, stage 4 pressure ulcers are characterized by full-thickness tissue loss, where the ulcer extends through the dermis and into the subcutaneous tissue, potentially exposing muscle, bone, or supporting structures. The affected areas may present with necrotic tissue and significant drainage. The back, buttock, and hip are common sites due to prolonged pressure, especially in immobile patients. Disease progression can lead to serious 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. Proper identification and staging are crucial for effective treatment planning and resource allocation in managing these complex wounds.
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
L89.44 specifically covers stage 4 pressure ulcers that occur on the back, buttock, and hip, characterized by full-thickness tissue loss and potential exposure of underlying structures. It is essential to differentiate this from other stages and types of ulcers.
L89.44 should be used when the pressure ulcer is confirmed as stage 4 on contiguous sites of the back, buttock, and hip. It is crucial to use this code when the ulcer presents with full-thickness tissue loss and significant complications, distinguishing it from lower-stage ulcers.
Documentation for L89.44 should include detailed clinical assessments, ulcer staging, descriptions of the wound characteristics, treatment plans, and any comorbid conditions that may affect healing. Photographic evidence and regular progress notes are also beneficial.
