How To Use CPT Code 15935

CPT 15935 describes the excision of a sacral pressure ulcer with skin flap closure and ostectomy. 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 15935?

CPT 15935 is used to describe the surgical procedure of removing a pressure sore and its underlying bone in the sacral area. The provider then closes the wound with a skin flap to ensure complete healing and prevent recurrence.

2. Official Description

The official description of CPT code 15935 is: ‘Excision, sacral pressure ulcer, with skin flap closure with ostectomy.’

3. Procedure

During the procedure, the patient is appropriately prepped and anesthetized. The provider makes an incision around the ulcerated region of the sacrum and removes the ulcerated tissue. Additionally, a portion of the underlying bone is excised. To close the wound from the ulcer excision, the provider selects a skin flap from another area of the body, typically from the groin, lifts the flap, and transfers it to the wound site.

4. Qualifying circumstances

CPT 15935 is performed on patients with sacral pressure ulcers, which are sores caused by mechanical pressure, traction, or friction on the skin. These ulcers often result from poor positioning and infrequent turning of immobile patients, leading to impaired blood supply and tissue death. The procedure is typically performed by a qualified healthcare professional who has determined that excision and closure with a skin flap and ostectomy are necessary for complete healing and prevention of recurrence.

5. When to use CPT code 15935

CPT code 15935 should be used when a provider performs the excision of a sacral pressure ulcer with skin flap closure and ostectomy. It is important to ensure that the procedure is performed specifically on the sacral area and not on other locations such as the coccygeal, ischial, or trochanteric regions, which have their own distinct codes within the Pressure Ulcers (Decubitus Ulcers) Procedures range.

6. Documentation requirements

To support a claim for CPT 15935, the provider must document the following information:

• Patient’s diagnosis of a sacral pressure ulcer
• Details of the excision procedure, including the incision, removal of ulcerated tissue, and ostectomy
• Description of the skin flap used for closure
• Date of the procedure
• Any additional relevant information or complications
• Provider’s signature

7. Billing guidelines

When billing for CPT 15935, ensure that the procedure is performed specifically on the sacral area and that all necessary documentation is provided. It is important to follow the guidelines for reporting pressure ulcer excision codes based on the specific location of the ulcer. Additionally, be aware of any specific coding rules or requirements from insurance payers.

8. Historical information

CPT 15935 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 15935

There are several similar codes to CPT 15935 within the Pressure Ulcers (Decubitus Ulcers) Procedures range. These codes include:

• CPT 15931: Excision, sacral pressure ulcer, with skin graft closure
• CPT 15932: Excision, sacral pressure ulcer, with myocutaneous flap closure
• CPT 15933: Excision, sacral pressure ulcer, with myocutaneous flap and ostectomy
• CPT 15934: Excision, sacral pressure ulcer, with myocutaneous flap, ostectomy, and bone graft
• CPT 15937: Excision, sacral pressure ulcer, with myocutaneous flap, ostectomy, and microvascular free tissue transfer

9. Examples

1. A patient with a sacral pressure ulcer undergoes excision of the ulcer and closure with a skin flap.
2. A healthcare provider performs an ostectomy along with the excision and closure of a sacral pressure ulcer using a skin flap.
3. A patient with a recurring sacral pressure ulcer undergoes excision, skin flap closure, and bone grafting for complete healing.
4. A provider performs excision, skin flap closure, ostectomy, and microvascular free tissue transfer for a complex sacral pressure ulcer.
5. A patient with a large sacral pressure ulcer undergoes excision, myocutaneous flap closure, and ostectomy to ensure complete healing and prevent recurrence.
6. A healthcare professional performs excision, skin flap closure, and ostectomy on a sacral pressure ulcer that has not responded to conservative treatment.
7. A patient with a deep sacral pressure ulcer undergoes excision, myocutaneous flap closure, and bone grafting for optimal wound healing.
8. A provider performs excision, skin flap closure, ostectomy, and myocutaneous flap for a sacral pressure ulcer with extensive tissue involvement.
9. A patient with a sacral pressure ulcer undergoes excision, skin flap closure, and ostectomy to address the underlying bone involvement.
10. A healthcare professional performs excision, myocutaneous flap closure, and ostectomy on a sacral pressure ulcer that has not responded to previous treatments.