How To Use CPT Code 15936

CPT code 15936 describes the excision of a sacral pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure. 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 15936?

CPT 15936 is used to describe the excision of a sacral pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure. This code is used when a healthcare provider removes the pressure sore located at the base of the spine and prepares the wound for closure with the use of a graft of skin or skin and muscle.

2. Official Description

The official description of CPT code 15936 is: ‘Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure.’

3. Procedure

During the procedure for CPT 15936, the healthcare provider first preps and anesthetizes the patient. Then, an incision is made around the ulcerated region of the sacrum, and the ulcerated tissue is removed. The provider then prepares the wound, creating a clean base for closure with a subsequent myocutaneous flap or a skin graft taken from a donor site, typically from the latissimus dorsi muscle.

4. Qualifying circumstances

CPT 15936 is used for patients with sacral pressure ulcers that require excision in preparation for muscle or myocutaneous flap or skin graft closure. The procedure is performed by a healthcare provider and is typically done when other conservative treatments have failed to heal the ulcer. The patient must have a documented sacral pressure ulcer that requires surgical intervention.

5. When to use CPT code 15936

CPT code 15936 should be used when a healthcare provider performs the excision of a sacral pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure. It is important to ensure that the procedure is medically necessary and meets the criteria for this specific code.

6. Documentation requirements

To support a claim for CPT 15936, the healthcare provider must document the following information:

• Patient’s diagnosis of a sacral pressure ulcer
• Details of the excision procedure performed
• Description of the wound preparation for closure
• Type of closure performed (muscle or myocutaneous flap or skin graft)
• Any additional procedures or treatments performed during the same encounter
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 15936, ensure that the excision of the sacral pressure ulcer is performed in preparation for muscle or myocutaneous flap or skin graft closure. It is important to follow the specific guidelines and documentation requirements outlined by the payer. It is also important to review any applicable bundling or unbundling rules and modifiers that may be required for accurate billing.

8. Historical information

CPT 15936 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates or changes since its addition.

9. Similar codes to CPT 15936

There are several similar codes to CPT 15936 that describe excision procedures for pressure ulcers in different anatomical locations. These include:

• CPT 15931: Excision, coccygeal pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
• CPT 15940: Excision, ischial pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
• CPT 15950: Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure

9. Examples

1. A healthcare provider performs the excision of a sacral pressure ulcer in preparation for a myocutaneous flap closure.
2. A patient with a sacral pressure ulcer undergoes excision of the ulcer in preparation for a skin graft closure.
3. A healthcare provider performs the excision of a sacral pressure ulcer in preparation for a muscle flap closure.
4. A patient with a sacral pressure ulcer undergoes excision of the ulcer in preparation for a myocutaneous flap closure.
5. A healthcare provider performs the excision of a sacral pressure ulcer in preparation for a skin and muscle graft closure.
6. A patient with a sacral pressure ulcer undergoes excision of the ulcer in preparation for a muscle and skin graft closure.
7. A healthcare provider performs the excision of a sacral pressure ulcer in preparation for a myocutaneous flap and skin graft closure.
8. A patient with a sacral pressure ulcer undergoes excision of the ulcer in preparation for a skin graft and muscle flap closure.
9. A healthcare provider performs the excision of a sacral pressure ulcer in preparation for a muscle flap and skin graft closure.
10. A patient with a sacral pressure ulcer undergoes excision of the ulcer in preparation for a skin and muscle flap closure.