How To Use CPT Code 15931

CPT code 15931 describes the excision of a sacral pressure ulcer with primary suture. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 15931?

CPT 15931 is used to describe the excision of a sacral pressure ulcer with primary suture. This procedure involves the removal of a pressure sore located at the base of the spine, specifically in the sacral region. The provider sutures the skin edges together to promote wound healing and prevent infection.

2. Official Description

The official description of CPT code 15931 is: ‘Excision, sacral pressure ulcer, with primary suture.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision, typically oval or elliptical in shape, around the ulcerated region of the sacrum.
3. The ulcerated tissue is carefully removed.
4. The wound is irrigated to ensure cleanliness.
5. The provider closes the wound with sutures.
6. A dressing is applied over the sutured wound to protect it.

4. Qualifying circumstances

CPT 15931 is applicable when a patient presents with a sacral pressure ulcer that requires excision and primary suture. Pressure ulcers, also known as decubitus ulcers, are caused by mechanical pressure, traction, or friction on the skin, often due to poor positioning and infrequent turning of an immobile patient. The procedure is performed by a qualified healthcare professional.

5. When to use CPT code 15931

CPT code 15931 should be used when a provider performs the excision of a sacral pressure ulcer with primary suture. It is important to accurately document the location of the ulcer and the specific procedure performed to support the use of this code.

6. Documentation requirements

To support a claim for CPT 15931, the following documentation is required:

• Identification of the patient’s sacral pressure ulcer
• Description of the excision procedure performed
• Date of the procedure
• Start and end time of the procedure
• Details of wound closure with primary suture
• Application of dressing
• Signature of the performing healthcare professional

7. Billing guidelines

When billing for CPT 15931, ensure that the excision of the sacral pressure ulcer with primary suture is accurately documented. It is important to follow the specific guidelines provided by the payer to ensure proper reimbursement. Additionally, consider any applicable modifiers that may be required for reporting this code.

8. Historical information

CPT 15931 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2010, with the description being updated to specify the excision of a sacral pressure ulcer with primary suture.

9. Examples

1. A patient with a sacral pressure ulcer undergoes excision of the ulcer with primary suture by a qualified healthcare professional.
2. A provider performs the excision of a sacral pressure ulcer with primary suture for a patient who has been suffering from prolonged immobility.
3. A sacral pressure ulcer is surgically removed and the wound is closed with sutures to promote healing and prevent infection.
4. A patient with a sacral pressure ulcer receives excision and primary suture as part of their comprehensive wound care treatment plan.
5. A healthcare professional performs the excision of a sacral pressure ulcer with primary suture to alleviate pain and promote healing for a bedridden patient.
6. A provider performs the excision of a sacral pressure ulcer with primary suture for a patient with limited mobility due to a medical condition.
7. A patient with a sacral pressure ulcer undergoes excision and primary suture to address the wound and prevent further complications.
8. A qualified healthcare professional performs the excision of a sacral pressure ulcer with primary suture to promote healing and prevent infection in a patient with compromised skin integrity.
9. A provider performs the excision of a sacral pressure ulcer with primary suture for a patient who has developed the ulcer due to prolonged pressure on the sacral region.
10. A patient with a sacral pressure ulcer receives excision and primary suture as part of their overall wound management plan to facilitate healing and prevent further deterioration.