CPT® Code 15936

A sacral pressure ulcer, commonly known as a pressure sore, bedsore, or decubitus ulcer, is a localized injury to the skin and underlying tissue, typically over bony prominences, due to prolonged pressure. The procedure described by CPT® Code 15936 involves the excision of this ulcer in preparation for subsequent closure using a muscle or myocutaneous flap or skin graft. The sacrum, which is the triangular bone located between the fifth lumbar vertebra and the coccyx, is the specific anatomical site addressed in this procedure. During the excision, the patient is positioned face down, allowing the physician to create an incision around the ulcer. This process entails the careful removal of all necrotic tissue, which includes the skin, subcutaneous tissue, and muscle, to ensure a clean wound bed. Additionally, any involved bursa and bone or bony protuberances may also be excised, with particular attention given to protecting surrounding nerves and blood vessels. After the excision, rough bony surfaces are smoothed, and the wound edges are trimmed to prepare the site for the subsequent placement of a muscle or myocutaneous flap or skin graft. Commonly utilized flaps for this closure include the superior gluteal myocutaneous flap, which involves the superior portion of the gluteus maximus muscle, and bilateral V-Y myocutaneous advancement flaps. It is important to note that this code is applicable when the procedure is performed without the removal of bone (ostectomy), while a different code, CPT® Code 15937, is used if ostectomy is performed.