Wound in the Buttocks Area: Terminology and ICD-10 Coding
A wound in the buttocks area is typically classified as a pressure injury (formerly called pressure ulcer) and is coded in the ICD-10 as L89.3 (Pressure ulcer of buttock).
Terminology for Buttocks Wounds
The terminology for wounds in the buttocks area depends on the etiology:
Pressure Injuries/Ulcers: Most common type of wound in the buttocks area, occurring over bony prominences due to unrelieved pressure
- Located over the sacrum, coccyx, or ischial tuberosities
- Staged from I-IV based on tissue involvement depth
Friction Injuries: Occur on the medial buttocks or posterior thighs
- Not located over bony prominences
- Caused by repetitive friction against surfaces 1
Moisture-Associated Skin Damage: Can occur in gluteal folds
- Related to excessive moisture and skin maceration
ICD-10 Coding for Buttocks Wounds
The primary ICD-10 code for buttocks wounds is L89.3 (Pressure ulcer of buttock), which is further specified by:
- L89.30: Pressure ulcer of buttock, unspecified stage
- L89.31: Pressure ulcer of buttock, stage 1
- L89.32: Pressure ulcer of buttock, stage 2
- L89.33: Pressure ulcer of buttock, stage 3
- L89.34: Pressure ulcer of buttock, stage 4
- L89.35: Pressure ulcer of buttock, unstageable
- L89.39: Pressure ulcer of buttock, unspecified stage
Staging of Pressure Injuries in the Buttocks
Proper staging is essential for accurate coding:
- Stage I: Non-blanchable erythema of intact skin
- Stage II: Partial-thickness skin loss with exposed dermis
- Stage III: Full-thickness skin loss (fat visible)
- Stage IV: Full-thickness skin and tissue loss with exposed muscle, tendon, or bone 2
- Unstageable: Full-thickness skin and tissue loss with slough or eschar covering the wound bed
Wound Assessment Parameters
For proper documentation and coding, assess:
- Wound size and depth
- Location (specific area of buttocks)
- Presence of eschar or granulation tissue
- Exudate amount and characteristics
- Odor
- Presence of sinus tracts or undermining
- Signs of infection 3
Diagnostic Approach
When evaluating a buttocks wound:
- Determine if the wound is over a bony prominence (suggests pressure injury)
- Use a sterile, blunt metal probe to measure depth and detect any bone exposure
- Assess for signs of infection (increased pain, erythema, warmth, purulent drainage)
- Document wound characteristics according to standardized classification systems 3
Coding Pitfalls to Avoid
- Don't automatically code all buttocks wounds as pressure injuries; consider friction injuries and moisture-associated damage as alternative diagnoses
- Ensure proper staging before assigning the specific ICD-10 code
- Document clearly whether bone is exposed or palpable with a probe (indicates Stage IV)
- For infected wounds, add appropriate infection codes
Remember that accurate terminology and coding are essential for proper treatment planning, reimbursement, and epidemiological tracking of these wounds.