CPT 15931: Excision of Sacral Pressure Sore with Primary Closure

CPT code 15931 represents surgical excision and primary closure of a pressure sore at the base of the spine (sacral pressure ulcer). This code captures a targeted operative procedure used to remove devitalized tissue and close the wound to reduce infection risk and facilitate healing. Nationally, management of advanced pressure injuries is an important component of surgical wound care and long-term chronic wound management, with implications for inpatient and ambulatory surgical utilization.

Key payers commonly involved in coverage decisions for this service include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical context for the procedure, typical sites of service, and the primary service description. The publication also covers payer coverage considerations and common billing modifiers where available, benchmarking and utilization patterns where data exist, and policy or documentation factors that affect claim adjudication.

This summary is intended for clinicians, coding professionals, and policy analysts seeking a concise reference for CPT code 15931, its clinical role in pressure sore management, and the payer landscape relevant to national billing and coverage discussions.

Billing Code Overview

CPT code 15931 describes surgical excision of a pressure sore located at the base of the spine with primary closure by suturing the skin edges. The procedure involves removal of necrotic or diseased tissue from a sacral pressure ulcer and closure of the wound to promote healing and reduce infection risk.

Service type: Surgical wound excision and primary closure
Typical site of service: Operative setting such as an ambulatory surgery center or hospital operating room

Clinical Context

A 72-year-old bedridden patient with limited mobility presents with a chronic, stage 3–4 pressure ulcer located at the sacrococcygeal region. The wound base shows viable tissue without extensive necrosis after initial debridement and infection control. The surgical team schedules a debridement and primary closure procedure to excise the pressure sore down to healthy tissue and approximate the skin edges with sutures to promote healing and reduce infection risk. Typical workflow: preoperative evaluation and optimization (wound culture, antibiotics if indicated), informed consent, regional or general anesthesia administered, excision of the pressure ulcer and any nonviable tissue, layered closure of the wound with appropriate deep and superficial sutures, application of dressing, and postoperative wound care instructions with planned outpatient or inpatient wound follow-up. Typical site of service is an outpatient ambulatory surgery center or hospital operating room. Service type: surgical wound excision and primary closure for a pressure ulcer at the base of the spine.

Coding Specifications

Modifier	Description	When to Use
`11`	Normal, upcoded to indicate the usual or default service	Use when the procedure was the standard service without unusual circumstances.
`22`

Taxonomy Code	Specialty	Notes
`207P00000X`	General Surgery	General surgeons commonly perform debridement and primary closure of pressure ulcers.
`2080P00000X`	Plastic Surgery	Plastic surgeons perform complex flap reconstructions or closures for sacral wounds.
`163WC0000X`	Wound Care Specialist (Podiatric/ wound-focused clinicians)	Providers with wound-care specialization often manage pre- and post-operative care and minor surgical debridement.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`L89.154`	Pressure ulcer of sacral region, stage 4	Represents a deep sacral pressure ulcer commonly requiring surgical excision and closure.
`L89.153`	Pressure ulcer of sacral region, stage 3	Deep tissue loss that may require debridement and primary closure depending on wound bed.
`L89.159`	Pressure ulcer of sacral region, unspecified stage	Used when stage is not documented but location is sacral and surgery is performed.
`L89.052`	Pressure ulcer of buttock, stage 2	Superficial ulcers that may still require operative intervention if nonhealing.
`E86.0`	Dehydration	Common comorbidity affecting wound healing and perioperative risk assessment.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`11042`	Debridement, subcutaneous tissue, first 20 sq cm or less	Often performed prior to or as part of wound bed preparation before excision and closure.
`11043`	Debridement, muscle and/or fascia, first 20 sq cm or less	Used when debridement extends into deeper tissues beneath a pressure ulcer.
`12032`	Layer closure of wounds of scalp, axillae, trunk and/or extremities; 2.6 cm to 7.5 cm	Example suture closure code for layered closure of defects after excision; may be billed for skin closure components when appropriate.
`13131`	Secondary intention repair, extensive scarring or loss of subcutaneous tissue; 10.1 cm to 30.0 cm	May be relevant when closure by secondary intention or complex revision is required.
`15734`	Muscle, myocutaneous or fasciocutaneous flap; trunk	Relevant if flap reconstruction is required for large sacral defects instead of primary closure.

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Summary & Overview