2025 CPT code 15958
(Active) Effective Date: N/A Surgery - Integumentary System Feed
Excision of a trochanteric pressure ulcer with ostectomy, preparing the site for muscle, myocutaneous flap, or skin graft closure.
Modifiers may be applicable to this code to indicate specific circumstances, such as increased procedural services (modifier 22) or multiple procedures (modifier 51).
Medical necessity for this procedure must be established by documenting the severity of the ulcer, failed conservative treatment attempts, presence of infection or osteomyelitis, and the need for surgical intervention to prevent further complications.
The physician performs the surgical excision of the pressure ulcer and the underlying bone. They also prepare the wound bed for the subsequent closure procedure.
In simple words: This procedure involves removing a pressure sore on the hip, along with the affected bone underneath, to prepare for a skin graft or flap surgery to close the wound.
Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy.This code includes the removal of the ulcer and underlying bone, creating a clean wound bed for subsequent flap or graft closure.The actual flap or graft application is reported separately.
Example 1: A patient presents with a large, stage IV pressure ulcer on the right trochanter with exposed bone. The physician excises the ulcer and performs an ostectomy to remove the infected bone. The wound is then prepared for a myocutaneous flap closure., A patient with a history of paraplegia has developed a deep trochanteric pressure ulcer with osteomyelitis.The physician removes the ulcerated tissue and affected bone, preparing the area for a skin graft., A nursing home resident with limited mobility has a chronic pressure ulcer on their left trochanter. After conservative treatments fail, the physician decides to excise the ulcer and remove the underlying bone in preparation for a muscle flap closure.
Documentation should include the size and location of the ulcer, the presence of bone involvement, the extent of the ostectomy, and the method of wound preparation.Operative notes should detail the procedure and any complications encountered. Photographs may also be beneficial.
- Specialties:Plastic Surgery, General Surgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center