Find information on stage 2 pressure ulcer left buttock diagnosis, including clinical documentation, medical coding, and treatment. Learn about pressure ulcer staging, wound care, and prevention strategies for stage 2 pressure injuries. This resource offers guidance for healthcare professionals on proper assessment, documentation, and ICD-10 coding for a stage 2 pressure ulcer located on the left buttock. Explore relevant information on pressure sore treatment, wound management, and preventing further complications.
Also known as
Pressure ulcer
Codes for pressure ulcers of specified sites.
Pressure ulcer of buttock
Includes pressure ulcers of right or left buttock.
Pressure ulcer left buttock
Classifies left buttock pressure ulcers by stage.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pressure ulcer stage 2?
Yes
Location: Left Buttock?
No
Specify Stage
When to use each related code
| Description |
|---|
| Stage 2 Pressure Ulcer Left Buttock |
| Stage 1 Pressure Ulcer Left Buttock |
| Deep Tissue Injury Left Buttock |
Documentation lacks specific details differentiating between stage 2 and other stages, leading to inaccurate coding (e.g., stage 1 or 3).
Documentation may fail to specify the affected buttock (left or right), impacting code selection and reimbursement.
Missing documentation linking the pressure ulcer to an underlying condition can affect coding accuracy and quality metrics.
Patient presents with a Stage 2 pressure ulcer on the left buttock. The wound bed is partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough. No granulation tissue is noted. The surrounding skin is intact with no signs of undermining or tunneling. The ulcer measures 2 cm x 3 cm. The patient reports mild pain at the site, rated 3 out of 10 on the pain scale. No purulent drainage or foul odor is present. The surrounding skin exhibits mild erythema. The patient's medical history includes type 2 diabetes mellitus and limited mobility due to recent hip surgery. Current medications include metformin and insulin. Diagnosis of pressure ulcer stage 2 left buttock is confirmed based on clinical presentation and National Pressure Ulcer Advisory Panel (NPUAP) staging guidelines. Treatment plan includes daily wound care with saline irrigation and application of a hydrocolloid dressing. Pressure redistribution measures, including a specialized mattress and frequent repositioning, are implemented. Nutritional assessment and optimization are recommended. Patient education provided regarding pressure ulcer prevention strategies and proper wound care techniques. Follow-up scheduled in one week to assess wound healing progress and adjust treatment plan as needed. ICD-10 code L89.152 assigned.