ICD-10 Coding for Buttocks Wound(L89.313, S31.83XA, T81.31XA)
Complete ICD-10-CM coding and documentation guide for Buttocks Wound. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Buttocks Wound
L89.3-L89.4Primary Range
Pressure ulcers of buttock
This range covers pressure ulcers specifically located on the buttocks, including various stages.
Open wound of buttock
This range is used for traumatic wounds on the buttocks, such as lacerations or punctures.
Complications of surgical wounds
This range includes complications such as infections or dehiscence of surgical wounds on the buttocks.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| L89.313 | Pressure ulcer of right buttock, stage 3 | Use when documenting a stage 3 pressure ulcer on the right buttock with full-thickness skin loss. |
|
| S31.83XA | Puncture wound without foreign body of buttock, initial encounter | Use for initial treatment of a traumatic puncture wound on the buttock. |
|
| T81.31XA | Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter | Use for initial encounter of a dehisced surgical wound on the buttock. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for buttocks wound
Essential facts and insights about Buttocks Wound
Primary ICD-10-CM Codes for buttocks wound
Decision Criteria
clinical Criteria
- Presence of full-thickness skin loss with visible fat
documentation Criteria
- Detailed wound assessment including size, depth, and tissue type
Applicable To
- Stage 3 pressure ulcer of right buttock
Excludes
- Non-pressure chronic ulcer of right buttock
Clinical Validation Requirements
- Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
- Visible fat but not muscle, bone, or tendon
Code-Specific Risks
- Misclassification of ulcer stage
- Incorrect laterality documentation
Coding Notes
- Ensure accurate documentation of ulcer stage and underlying conditions.
S31.83XA - Puncture wound without foreign body of buttock, initial encounter
Use for initial treatment of a traumatic puncture wound on the buttock.
Applicable To
- Traumatic puncture wound of buttock
Excludes
- Pressure ulcer of buttock
Clinical Validation Requirements
- Documented mechanism of injury (e.g., fall onto sharp object)
- Absence of foreign body
Coding Notes
Ensure documentation includes the mechanism of injury and foreign body status.
T81.31XA - Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter
Use for initial encounter of a dehisced surgical wound on the buttock.
Applicable To
- Dehiscence of surgical wound on buttock
Excludes
- Infection of surgical wound
Clinical Validation Requirements
- Visible separation of surgical wound edges
- Documentation of surgical history
Coding Notes
Ensure surgical history and wound status are clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for attention to dressings, sutures, and drains
Z48.0Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Pressure ulcer of right buttock, stage 4
L89.314Puncture wound with foreign body of buttock, initial encounter
S31.84XAInfection following a procedure
T81.4Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Buttocks Wound to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.313.
Impact
Clinical: Inadequate treatment planning, Regulatory: Non-compliance with coding guidelines, Financial: Potential for claim denials
Mitigation Strategy
Always assess and document underlying conditions, Link conditions to wound codes
Impact
Reimbursement: Incorrect laterality can lead to claim denials., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Impacts the accuracy of patient records.
Mitigation Strategy
Always specify the side of the buttock affected.
Impact
Reimbursement: Incorrect staging can affect DRG assignment., Compliance: Non-compliance with clinical documentation standards., Data Quality: Leads to inaccurate clinical data.
Mitigation Strategy
Ensure accurate staging based on clinical assessment.
Impact
Incorrect staging can lead to audit flags.
Mitigation Strategy
Regular training on staging criteria and documentation.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Buttocks Wound, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Buttocks Wound
Use these documentation templates to ensure complete and accurate documentation for Buttocks Wound. These templates include all required elements for proper coding and billing.
Pressure Ulcer Documentation
Specialty: Wound CareRequired Elements
- Location and size of ulcer
- Stage and tissue type
- Presence of infection or necrosis
- Patient mobility status
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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