2025 CPT code 15936
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Integumentary System Feed
Excision of a sacral pressure ulcer in preparation for muscle or myocutaneous flap or skin graft closure.
Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (modifier 22) or a distinct procedural service (modifier 59) if other procedures are performed at the same surgical session.
Medical necessity for 15936 is established when the sacral pressure ulcer is severe enough to require surgical excision and preparation for flap or graft closure, typically in cases where primary closure is not feasible due to the size, depth, or condition of the wound.
The surgeon prepares the patient, creates an incision around the ulcer on the sacrum, removes the damaged tissue, and prepares the wound bed for subsequent closure with a flap or graft.This often involves meticulous dissection to preserve healthy tissue and ensure a clean wound bed.
In simple words: The surgeon removes a pressure sore at the base of the spine and prepares the area for a skin or skin and muscle graft.
This code describes the surgical removal of a pressure ulcer located on the sacrum (base of the spine) in anticipation of a subsequent closure using a muscle or myocutaneous flap or skin graft.This procedure involves excising the ulcerated tissue and preparing the wound bed for the future flap or graft, but does not include the actual flap or graft procedure itself.
Example 1: A patient with a stage IV sacral pressure ulcer, unsuitable for primary closure, undergoes excision of the ulcer in preparation for a latissimus dorsi myocutaneous flap closure at a later date., A diabetic patient with a deep sacral pressure ulcer, complicated by infection and necrotic tissue, requires excision of the ulcer. The wound is then prepared for a skin graft application after the infection is resolved., A patient with a large sacral pressure ulcer extending to the bone undergoes excision of the ulcerated tissue and partial sacrectomy. The wound is prepared for closure with a gluteus maximus myocutaneous flap in a staged procedure.
Documentation should include the location and size of the ulcer, the depth of tissue involvement (stage of the ulcer), the presence of any infection or necrosis, the extent of debridement, and the planned method of closure (type of flap or graft). Operative notes should detail the excision procedure and preparation of the wound bed.
- Revenue Code: P1G - Major Procedure - Other
- Payment Status: Active
- Specialties:Plastic Surgery, General Surgery, Wound Care
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center