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The procedure described by CPT® Code 15922 involves the excision of a coccygeal pressure ulcer, which is commonly known as a pressure sore, bedsore, or decubitus ulcer. This type of ulcer occurs on the coccyx, the small triangular bone located at the base of the spine, formed by the fusion of four coccygeal vertebrae. The procedure is performed with the patient in a prone position, allowing the physician to access the affected area effectively. An elliptical incision is made around the pressure ulcer to excise the damaged tissue. Following the excision, the coccyx is exposed, and the physician carefully dissects it free from the surrounding tissue, elevating the tip of the coccyx with a finger. The coccyx is then severed at the sacrococcygeal joint and completely removed. To ensure proper healing and closure of the wound, any rough bony surfaces are smoothed out. Unlike the procedure described in CPT® Code 15920, which utilizes primary suture repair for wound closure, CPT® Code 15922 employs a local skin flap technique. This involves incising the skin adjacent to the wound down to the level of subcutaneous fat, mobilizing the skin, and then rotating or advancing the skin flap to cover the excised area. The skin flap is sutured in place, and the donor site is also repaired with sutures, ensuring a comprehensive approach to wound closure and recovery.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 15922 is indicated for patients presenting with a coccygeal pressure ulcer, which may also be referred to as a pressure sore, bedsore, or decubitus ulcer. These ulcers typically develop due to prolonged pressure on the coccyx, often in individuals with limited mobility or those who are bedridden. The presence of a coccygeal pressure ulcer may be associated with symptoms such as pain, discomfort, and potential infection, necessitating surgical intervention to promote healing and prevent further complications.
The procedure for CPT® Code 15922 involves several critical steps to ensure the effective excision of the coccygeal pressure ulcer and subsequent closure of the wound. Initially, the patient is positioned face down to provide optimal access to the coccygeal area. The physician begins by making an elliptical incision around the pressure ulcer, carefully excising the affected tissue. Once the ulcer is removed, the coccyx is exposed, allowing the physician to elevate the tip of the coccyx using a finger. This step is crucial as it enables the physician to dissect the coccyx free from the surrounding underlying tissue, continuing the dissection up to the level of the sacrum. The coccyx is then severed at the sacrococcygeal joint, ensuring complete removal of the bone. After excision, any rough bony surfaces are smoothed using a file to promote better healing. Unlike the procedure described in CPT® Code 15920, which utilizes primary suture repair, CPT® Code 15922 employs a local skin flap technique for wound closure. The physician incises the skin adjacent to the wound down to the level of subcutaneous fat, allowing for the mobilization of the skin. The skin flap is then rotated or advanced to cover the excised area and is sutured in place. Finally, the donor site from where the skin flap was taken is also repaired with sutures, completing the procedure.
Post-procedure care following the excision of a coccygeal pressure ulcer with coccygectomy and flap closure is essential for optimal recovery. Patients may be monitored for signs of infection at the surgical site, and pain management strategies should be implemented to ensure comfort. It is crucial to follow up with the patient to assess the healing of the wound and the integrity of the skin flap. Patients may be advised on mobility restrictions to prevent undue pressure on the surgical site during the initial recovery phase. Additionally, education on proper wound care and hygiene practices will be provided to minimize the risk of complications and promote healing. Regular follow-up appointments may be necessary to evaluate the healing process and address any concerns that may arise during recovery.
| Short Descr | EXC COCCYGL PR ULC FLAP CLSR | Medium Descr | EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR | Long Descr | Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5A - Ambulatory procedures - skin | MUE | 1 | CCS Clinical Classification | 142 - Partial excision bone |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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