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A trochanteric pressure ulcer, commonly known as a pressure sore, bedsore, or decubitus ulcer, is a type of wound that develops over the greater trochanter, which is a prominent bony projection located at the proximal end of the femur. This area serves as an attachment point for various muscles in the thigh and buttock. The development of a trochanteric pressure ulcer is often associated with prolonged pressure on the skin, typically occurring in individuals who are immobile or have limited mobility. The procedure described by CPT® Code 15953 involves the excision of the trochanteric pressure ulcer along with a skin flap closure and ostectomy. During this surgical intervention, the physician makes an elliptical incision around the ulcer, excising all necrotic tissue, which includes skin, subcutaneous tissue, and muscle. The procedure also entails inspecting the trochanteric bursa and bone, resecting the bursa, and excising any involved bone or bony protuberances while ensuring the protection of surrounding nerves and blood vessels. The remaining rough bony surfaces are smoothed, and the wound is subsequently closed using a local skin flap, which involves mobilizing adjacent skin and suturing it over the wound to promote healing and restore the integrity of the skin in the affected area.
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The procedure described by CPT® Code 15953 is indicated for the treatment of trochanteric pressure ulcers, which may arise due to prolonged pressure on the skin, particularly in patients with limited mobility. The following conditions may warrant this surgical intervention:
The procedure for CPT® Code 15953 involves several critical steps to ensure the effective excision of the trochanteric pressure ulcer and proper closure of the wound:
After the procedure, patients may require specific post-operative care to ensure proper healing of the surgical site. This may include monitoring for signs of infection, managing pain, and ensuring that the surgical site remains clean and dry. Patients may also need to follow specific instructions regarding mobility and pressure relief to prevent the development of new pressure ulcers. Regular follow-up appointments may be necessary to assess the healing process and address any complications that may arise.
| Short Descr | EXC TRCHNTR PR ULC FLP OSTC | Medium Descr | EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY | Long Descr | Excision, trochanteric 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) | 1 - Statutory payment restriction for assistants at surgery applies 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 | 2 | CCS Clinical Classification | 142 - Partial excision bone |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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