L89.313 Pressure ulcer of right buttock, stage 3

ICD10CM code

#### Name of the Condition
- Pressure Ulcer of Right Buttock, Stage 3
- Also known as Stage 3 Decubitus Ulcer

#### Summary
Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. A Stage 3 pressure ulcer is a severe type where the wound extends through the full thickness of the skin and into the underlying tissue, but not through the muscle or bone.

#### Causes
- Sustained pressure on the skin, often due to immobility or prolonged sitting/lying in one position.
- Shear and friction forces on the skin.
- Poor circulation and lack of movement, especially in individuals who are bedridden or use a wheelchair.

#### Risk Factors
- Advanced age and immobility.
- Conditions such as paralysis or coma.
- Malnutrition and dehydration.
- Conditions causing impaired sensory perception or circulation, like diabetes or vascular disease.

#### Symptoms
- Open wound or sore on the right buttock, possibly with a crater appearance.
- Slough (yellowish or dead tissue) or eschar (hard, dead tissue) may be present.
- Pain, tenderness, or discomfort in the affected area.
- Possible signs of infection (redness, warmth, and swelling).

#### Diagnosis
- Physical examination by a healthcare professional.
- Assessment of the size, depth, and condition of the ulcer.
- Additional tests for infection if needed, such as bacterial cultures from the wound.

#### Treatment Options
- Cleaning and dressing of the wound to prevent infection.
- Debridement to remove dead tissue.
- Pressure relief techniques, such as repositioning or using specialized mattresses or cushions.
- Nutritional support to promote healing.
- Surgical intervention in severe cases to repair the wound.

#### Prognosis and Follow-Up
- The healing process can be prolonged and requires diligent care.
- Regular follow-up appointments to monitor healing progress and adjust care plans as needed.
- Education on pressure relief techniques and skin care is crucial for prevention.

#### Complications
- Infection in the ulcer or deeper tissues like bones.
- Delayed wound healing leading to chronic sores.
- Impact on quality of life due to pain and discomfort.
- Potential for sepsis if not treated promptly.

#### Lifestyle & Prevention
- Frequent repositioning to alleviate pressure.
- Use of supportive surfaces such as mattresses or cushions.
- Maintaining good nutrition and hydration.
- Regular skin inspections, especially in high-risk individuals.

#### When to Seek Professional Help
- If a new sore develops or existing sores worsen.
- Signs of infection, such as increased redness, swelling, or drainage.
- Uncontrolled pain around the ulcer area.

#### Additional Resources
- National Pressure Ulcer Advisory Panel (NPUAP) - [Website](http://www.npuap.org)
- Wound, Ostomy, and Continence Nurses Society (WOCN) - [Website](https://www.wocn.org)

#### Tips for Medical Coders
- Ensure correct laterality is recorded (right buttock in this case).
- Document the stage of the pressure ulcer accurately as Stage 3.
- Avoid confusing with other conditions or incorrect stages of ulcers.

Medical Policies and Guidelines for Pressure ulcer of right buttock, stage 3

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