How To Use CPT Code 15958

CPT code 15958 describes the excision of a trochanteric pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure with 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 15958?

CPT 15958 is used to describe the excision of a trochanteric pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure with ostectomy. This code is used when the provider removes the pressure ulcer and underlying bone of the trochanter of the hip area, preparing the wound for closure by a myocutaneous flap or skin graft.

2. Official Description

The official description of CPT code 15958 is: ‘Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure with ostectomy.’

3. Procedure

During the procedure, the provider makes an incision around the ulcerated region of the trochanter and removes the ulcerated tissue. They also remove the nearby part of the bone to help prevent recurrence or remove infection. The wound is then prepared for closure by a separately reportable service involving a myocutaneous flap or a skin graft taken from a donor site, usually from the tensor fasciae latae muscle.

4. Qualifying circumstances

Patients eligible for CPT 15958 are those with trochanteric pressure ulcers requiring excision and preparation for closure with a myocutaneous flap or skin graft. The procedure is performed by a qualified healthcare provider. It is important to note that for repair of the defect using a muscle or myocutaneous flap, additional codes (15734 and/or 15738) should be used in addition to 15956 and 15958. For repair using a split skin graft, additional codes (15100 and/or 15101) should be used in addition to 15956 and 15958.

5. When to use CPT code 15958

CPT code 15958 should be used when the provider performs the excision of a trochanteric pressure ulcer in preparation for closure with a myocutaneous flap or skin graft. It is important to ensure that the procedure involves the removal of the pressure ulcer and underlying bone and that it is being prepared for closure with a flap or graft.

6. Documentation requirements

To support a claim for CPT 15958, the provider must document the following information:

• Patient’s diagnosis of a trochanteric pressure ulcer
• Details of the excision procedure, including the incision and removal of ulcerated tissue and bone
• Description of the myocutaneous flap or skin graft closure being prepared
• Date of the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 15958, ensure that the procedure involves the excision of a trochanteric pressure ulcer in preparation for closure with a myocutaneous flap or skin graft. It is important to use the appropriate additional codes (15734 and/or 15738 for muscle or myocutaneous flap repair, 15100 and/or 15101 for split skin graft repair) if applicable. Follow any specific guidelines provided by the payer regarding the reporting of this code.

8. Historical information

CPT 15958 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Similar codes to CPT 15958

Five similar codes to CPT 15958 include:

• CPT 15956: Excision, pressure ulcer, with removal of necrotic tissue; without ostectomy (use when there is no involvement of bone in the procedure)
• CPT 15937: Excision, pressure ulcer, sacral (use for excision of pressure ulcer and removal of bone over the sacral region)
• CPT 15946: Excision, pressure ulcer, ischial (use for excision of pressure ulcer and removal of bone over the ischial region)
• CPT 15734: Muscle, myocutaneous, or fasciocutaneous flap; trunk (use for repair of defect using a muscle or myocutaneous flap)
• CPT 15738: Muscle, myocutaneous, or fasciocutaneous flap; upper extremity (use for repair of defect using a muscle or myocutaneous flap)

9. Examples

1. A provider performs the excision of a trochanteric pressure ulcer and prepares the wound for closure with a myocutaneous flap.
2. A patient with a trochanteric pressure ulcer undergoes excision of the ulcer and preparation for closure with a skin graft.
3. A provider removes an ulcerated tissue and underlying bone of a trochanteric pressure ulcer in preparation for closure with a myocutaneous flap.
4. A patient with a trochanteric pressure ulcer undergoes excision of the ulcer and preparation for closure with a skin graft taken from a donor site.
5. A provider performs the excision of a trochanteric pressure ulcer and prepares the wound for closure with a myocutaneous flap taken from the tensor fasciae latae muscle.
6. A patient with a trochanteric pressure ulcer undergoes excision of the ulcer and preparation for closure with a skin graft taken from a donor site, usually from the tensor fasciae latae muscle.
7. A provider removes an ulcerated tissue and underlying bone of a trochanteric pressure ulcer in preparation for closure with a myocutaneous flap taken from the tensor fasciae latae muscle.
8. A patient with a trochanteric pressure ulcer undergoes excision of the ulcer and preparation for closure with a skin graft taken from a donor site, usually from the tensor fasciae latae muscle.
9. A provider performs the excision of a trochanteric pressure ulcer and prepares the wound for closure with a myocutaneous flap taken from the tensor fasciae latae muscle.