L89.314

Billable

Pressure ulcer of right buttock, stage 4

HCC Category Mapping

V28HCC 379 — Pressure Ulcer of Skin with Full Thickness Skin Loss

0.662

V24HCC 157 — Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

1.071

ESRDHCC 157 — Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone

0.000

What This Code Means

The most severe pressure ulcer on the right buttock with full-thickness skin loss and exposure of underlying bone, tendon, or muscle.

Coding Tips

•Stage 4 is the most advanced; ensure documentation clearly identifies exposed deep structures
•Document the extent of tissue involvement and any complications such as infection or osteomyelitis

Clinical Significance

Stage 4 pressure ulcers of the right buttock are the most severe classification with exposed bone, muscle, or tendon. The ischial tuberosity is commonly involved in buttock stage 4 wounds, creating risk for ischial osteomyelitis. These wounds require aggressive surgical and medical management and represent extreme clinical complexity with significant mortality risk.

Documentation Requirements

✓Anatomical location specified as right buttock
✓Stage explicitly documented as stage 4
✓Specific exposed structures identified (ischial bone, gluteal muscle, tendon)
✓Complete wound measurements
✓Undermining and tunneling documentation
✓Osteomyelitis assessment (imaging, bone biopsy)
✓Wound cultures
✓Nutritional labs
✓Surgical consultation
✓Comprehensive treatment plan

Commonly Confused Codes

L89.313 — Stage 3 right buttock; NO deep structure exposure L89.310 — Unstageable right buttock; wound bed obscured L89.324 — Stage 4 left buttock; laterality difference L89.214 — Stage 4 right hip; different anatomical site

Code Hierarchy

└L89Pressure ulcer └L89.3Pressure ulcer of buttock └L89.31Pressure ulcer of right buttock └L89.314Pressure ulcer of right buttock, stage 4

└L89.314Pressure ulcer of right buttock, stage 4