© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 15934 refers to the surgical procedure for the excision of a sacral pressure ulcer, which is commonly known as a pressure sore, bedsore, or decubitus ulcer. This type of ulcer occurs on the sacrum, the triangular bone located between the fifth lumbar vertebra and the coccyx. The procedure typically involves the patient lying face down to allow the physician access to the affected area. An elliptical incision is made around the pressure ulcer to excise the damaged tissue. Following the excision, a local skin flap is utilized to close the wound. This involves incising the skin adjacent to the ulcer down to the level of subcutaneous fat, allowing the skin to be mobilized effectively. The skin flap is then rotated or advanced over the excised area and sutured in place to promote healing. Additionally, the donor site from which the skin flap was taken is also repaired with sutures to ensure proper closure and recovery. This procedure is critical for managing sacral pressure ulcers, as it not only removes the damaged tissue but also facilitates the healing process through the use of local skin flaps.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 15934 is indicated for patients presenting with a sacral 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 skin, often in individuals with limited mobility or those who are bedridden. The primary indications for performing this excision include:
The procedure for CPT® Code 15934 involves several critical steps to ensure the effective excision and closure of the sacral pressure ulcer. The steps are as follows:
Post-procedure care following the excision of a sacral pressure ulcer with skin flap closure is essential for optimal recovery. Patients are typically monitored for signs of infection at the surgical site, and appropriate wound care instructions are provided. This may include keeping the area clean and dry, changing dressings as directed, and avoiding pressure on the surgical site to promote healing. Pain management may also be addressed as needed. Follow-up appointments are crucial to assess the healing process and to ensure that the skin flap is integrating properly with the surrounding tissue. Any complications, such as flap failure or recurrence of the ulcer, should be promptly addressed by the healthcare provider.
| Short Descr | EXC SACRAL PR ULC SKN FLAP | Medium Descr | EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR | Long Descr | Excision, sacral pressure ulcer, with skin 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 170 - Excision of skin lesion |
| 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2025-01-01 | Changed | Short Description changed. |
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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