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A sacral pressure ulcer, commonly known as a pressure sore, bedsore, or decubitus ulcer, occurs on the sacrum, which is the triangular bone located between the fifth lumbar vertebra and the coccyx. This type of ulcer typically develops due to prolonged pressure on the skin, often in individuals who are bedridden or have limited mobility. The procedure described by CPT® Code 15935 involves the excision of the sacral pressure ulcer, which is a surgical intervention aimed at removing the ulcer and any underlying affected tissue. During the procedure, the patient is positioned face down to allow access to the sacral area. The physician makes an elliptical incision around the ulcer to excise the damaged tissue. Following the excision, the underlying sacral bone is inspected for any involvement, and if necessary, any bony protuberances or affected bone is removed. The remaining rough surfaces of the bone are smoothed to promote healing. The wound is then closed using a local skin flap technique, which involves mobilizing adjacent skin to cover the excised area, ensuring proper closure and minimizing the risk of complications. This procedure is critical for patients with significant pressure ulcers, as it addresses both the ulcer and any underlying issues that may impede healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 15935 is indicated for patients presenting with a sacral pressure ulcer that requires surgical intervention. The following conditions may warrant this procedure:
The procedure for excising a sacral pressure ulcer with skin flap closure and ostectomy involves several critical steps:
After the procedure, the patient will require careful monitoring and post-operative care to ensure proper healing of the surgical site. This may include pain management, wound care, and regular assessments to monitor for signs of infection or complications. The patient may also need to follow specific guidelines for mobility and pressure relief to prevent the recurrence of pressure ulcers. Follow-up appointments will be necessary to evaluate the healing process and make any adjustments to the care plan as needed.
| Short Descr | EXC SAC PR ULC SKN FLP OSTC | Medium Descr | EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY | Long Descr | Excision, sacral pressure ulcer, with skin flap closure; with ostectomy | 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) | P1G - Major procedure - Other | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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