CPT® Code 15958

A trochanteric pressure ulcer, commonly known as a pressure sore, bedsore, or decubitus ulcer, is a localized injury to the skin and underlying tissue that typically occurs over bony prominences, such as the greater trochanter of the femur. This procedure involves the excision of the ulcer in preparation for subsequent closure using a muscle or myocutaneous flap or skin graft. The greater trochanter is a prominent bony structure located on the outer aspect of the femur, serving as an attachment point for various muscles of the thigh and buttock. During the excision, the physician makes an incision around the ulcer, carefully removing all necrotic tissue, which includes the skin, subcutaneous tissue, and any affected muscle. In some cases, the procedure may also involve the excision of the bursa and any involved bone or bony protuberances, ensuring that surrounding nerves and blood vessels are protected throughout the process. After the excision, any rough bony surfaces are smoothed to prepare the wound bed adequately for the placement of the muscle or myocutaneous flap or skin graft. Common types of flaps that may be utilized include the tensor fascia lata flap, vastus lateralis myocutaneous flap, gluteal thigh flap, and anterior thigh flap. It is important to note that this procedure is coded as CPT® 15958 when ostectomy is performed, while CPT® 15956 is used when the procedure is conducted without the removal of bone.