L98.415
BillableNon-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis
HCC Category Mapping
V28HCC 380 — Chronic Ulcer of Skin, Except Pressure
0.426V24HCC 161 — Chronic Ulcer of Skin, Except Pressure
0.426ESRDHCC 161 — Chronic Ulcer of Skin, Except Pressure
0.000RxHCCHCC 311 — Diabetic and Chronic Skin Ulcer
0.000What This Code Means
A chronic open sore on the buttock with damage extending into the muscle layer, but without dead muscle tissue present.
Coding Tips
- •Differentiate from L98.413 by confirming muscle involvement WITHOUT necrosis in clinical documentation
- •Document muscle involvement through examination findings or imaging confirmation
Clinical Significance
Non-pressure chronic ulcers of the buttock with deep tissue involvement (without necrosis) indicate significant wound depth requiring specialized wound care and monitoring. While the tissue remains viable, the depth of involvement signals ongoing risk for progression to necrosis and potential complications. Accurate coding of the tissue involvement level is essential for appropriate risk adjustment and care planning.
Documentation Requirements
- ✓Provider documentation of the ulcer as chronic (present for extended duration, not acute)
- ✓Anatomical location clearly specified as buttock
- ✓Confirmation that the ulcer is non-pressure in etiology (e.g., venous, arterial, inflammatory, or other documented cause)
- ✓Description of wound bed characteristics and tissue involvement depth
- ✓Documentation of muscle layer exposure or involvement without evidence of necrosis
- ✓Statement confirming muscle tissue is viable (not necrotic)
- ✓Wound measurements (length, width, depth) and assessment of wound edges and surrounding tissue
- ✓Current treatment plan including wound care interventions
Commonly Confused Codes
L89.3xx — Pressure ulcer of buttock; use when ulcer is caused by sustained pressure, not for non-pressure etiologiesL98.42x — Non-pressure chronic ulcer of back; differs by anatomical location (back vs. buttock)L98.49x — Non-pressure chronic ulcer of other sites; use only when location does not match buttock, back, or specified sitesL97.x — Non-pressure chronic ulcer of lower leg; different anatomical site entirelyL98.413 — Same site with necrosis of muscle; use when muscle tissue is dead/necrotic, not merely involved
Code Hierarchy
└L98Other disorders of skin and subcutaneous tissue, not elsewhere classified└L98.4Non-pressure chronic ulcer of skin, not elsewhere classified└L98.41Non-pressure chronic ulcer of buttock└L98.415Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis
└L98.415Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis