ICD-10 Coding for Stage 2 Pressure Ulcer Left Buttock(L89.322)
Complete ICD-10-CM coding and documentation guide for Stage 2 Pressure Ulcer Left Buttock. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Stage 2 Pressure Ulcer Left Buttock
L89.3-L89.4Primary Range
Pressure ulcers of the buttock
This range includes codes for pressure ulcers specifically located on the buttocks, including different stages.
Key Information: ICD-10 code for stage 2 pressure ulcer left buttock
Essential facts and insights about Stage 2 Pressure Ulcer Left Buttock
Primary ICD-10-CM Code for stage 2 pressure ulcer left buttock
Decision Criteria
clinical Criteria
- Partial-thickness dermal loss without slough or granulation
documentation Criteria
- Explicit mention of 'stage 2' in the medical record
Applicable To
- Stage 2 pressure ulcer of left buttock
Excludes
- Pressure ulcer of unspecified stage
- Pressure ulcer of other sites
Clinical Validation Requirements
- Partial-thickness loss of dermis
- Shallow open ulcer with red-pink wound bed
- No slough or granulation tissue
Code-Specific Risks
- Misstaging due to incorrect documentation of slough or granulation
Coding Notes
- Ensure documentation clearly states 'stage 2' and describes the ulcer as partial-thickness without slough.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unspecified bacterial infection
B96.5Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Pressure ulcer of left buttock, stage 3
L89.323Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Stage 2 Pressure Ulcer Left Buttock to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.322.
Impact
Clinical: Leads to inaccurate clinical data., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect reimbursement.
Mitigation Strategy
Ensure documentation specifies the ulcer stage., Educate providers on the importance of detailed documentation.
Impact
Reimbursement: Incorrect staging can lead to improper DRG assignment., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of clinical data and quality measures.
Mitigation Strategy
Query the provider to confirm the stage if granulation is documented.
Impact
Misstaging due to inadequate documentation.
Mitigation Strategy
Implement regular training sessions for providers on documentation standards.
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 Stage 2 Pressure Ulcer Left Buttock, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Stage 2 Pressure Ulcer Left Buttock
Use these documentation templates to ensure complete and accurate documentation for Stage 2 Pressure Ulcer Left Buttock. These templates include all required elements for proper coding and billing.
Documenting a stage 2 pressure ulcer on the left buttock
Specialty: Wound CareRequired Elements
- Location: Left buttock
- Size: Dimensions of the ulcer
- Stage: 2
- Tissue: Partial-thickness loss, no slough
- Edges: Defined
- Exudate: None or serous
- Surrounding skin: Non-blanchable erythema
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Stage 2 Pressure Ulcer Left Buttock? Ask your questions below.