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CPT 15936: Excision of Sacral Pressure Sore with Skin or Muscle Graft

CPT code 15936 denotes surgical removal of a pressure sore at the base of the spine with preparation for closure using a skin or skin-and-muscle graft. This procedure addresses complex sacral pressure ulcers that require debridement and reconstructive grafting to promote wound healing and prevent recurrent infection. Nationally, management of pressure injuries is a significant surgical and cost concern due to an aging population and prevalence among patients with limited mobility.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical and billing overview of the procedure, typical sites of service, and the care context in which this code is used. The publication outlines common billing considerations, typical modifiers (listed separately), and the clinical rationale for grafting versus simpler closure techniques. It also highlights where data was not provided and notes that payer-specific coverage policies and payment rates vary.

This summary equips coding professionals, surgical teams, and policy analysts with a clear description of what CPT code 15936 represents, the clinical circumstances prompting its use, and the types of payers that commonly cover this service. Data not available in the input includes specific payer payment rates, associated taxonomies, and ICD-10 diagnosis pairings.

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Billing Code Overview

CPT code 15936 describes excision of a pressure sore located at the base of the spine with preparation of the wound for closure using a skin graft or a combined skin and muscle graft. The procedure is a surgical intervention focused on debridement and reconstruction of a sacral (base-of-spine) pressure ulcer.

Service type: Surgical debridement with grafting and wound reconstruction
Typical site of service: Operating room or surgical suite, commonly performed by specialists in plastic surgery, general surgery, or wound care teams

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CPT 15936: Excision of Sacral Pressure Sore with Skin or Muscle Graft

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Billing Code Overview

Service type: Surgical debridement with grafting and wound reconstruction
Typical site of service: Operating room or surgical suite, commonly performed by specialists in plastic surgery, general surgery, or wound care teams

Clinical & Coding Specifications

Clinical Context

A 62-year-old wheelchair-dependent patient with a chronic, nonhealing stage IV sacral decubitus ulcer is admitted for operative management. After failed conservative care including offloading, wound care, and antibiotics for surrounding cellulitis, the surgical team performs operative debridement of necrotic tissue at the base of the spine and prepares the defect for definitive closure using a skin graft or a myocutaneous flap (graft of skin or skin and muscle). The patient is evaluated preoperatively by the attending surgeon and anesthesia team, consented for debridement with graft or flap, and receives perioperative antibiotics. Intraoperative steps include radical debridement to healthy bleeding tissue, irrigation, assessment of wound dimensions, and harvest and placement of an appropriate graft or flap (such as a gluteal or paraspinous muscle flap with overlying skin). Postoperative care includes flap monitoring, wound dressings, offloading, pain control, and coordination with physical therapy and wound care nursing for pressure redistribution and ongoing surveillance to reduce recurrence risk.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when a substantially greater service was provided due to increased complexity of debridement or extensive reconstruction beyond typical expectations.
`23`	Unusual anesthesia	Use when anesthesia is medically contraindicated and heavy sedation or general anesthesia is not used, or when unusual circumstances require alternative anesthesia documentation.
`26`	Professional component	Use when reporting only the physician's professional component separate from technical facility services (rare for this operative code).
`50`	Bilateral procedure	Use when identical procedures are performed bilaterally (not commonly applicable for a single sacral pressure sore).
`51`	Multiple procedures	Use when this procedure is performed in the same operative session with other distinct surgical procedures; list primary and add `51` to secondary codes per payer rules.
`52`	Reduced services	Use when the service is partially reduced or not completed as originally planned (document reason for reduction).
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances; document reason for discontinuation.
`62`	Two surgeons	Use when two surgeons from different specialties work together substantially for the procedure (e.g., plastic surgeon assisting a general surgeon).
`66`	Surgical team (multiple surgeons)	Use when more than two surgeons are required and documented as a surgical team approach.
`78`	Unplanned return to OR	Use when the patient returns to the operating room for a related procedure during the global period due to complications.
`80`	Assistant surgeon	Use when an assistant surgeon is present and documentation supports assistant services.
`81`	Minimum assistant surgeon	Use when a minimal assistant is documented and meets payer criteria.
`82`	Assistant surgeon when qualified resident not available	Use when a qualified resident is not available and an assistant surgeon is required.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for surgical procedures	Use when an advanced practice clinician performs or assists in portions of the procedure as permitted by payer policy.

Taxonomy Code	Specialty	Notes
207P00000X	Physical Medicine & Rehabilitation	Often involved in pre/postoperative rehabilitation and pressure offloading plans.
207L00000X	Surgery — General	Frequently performs initial debridement and wound management.
208C00000X	Surgery — Plastic	Commonly performs myocutaneous flap reconstruction or complex wound closure.
163W00000X	Wound Care	Specialist clinicians focused on chronic wound assessment and longitudinal care.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`L89.153`	Pressure ulcer of sacral region with necrosis of muscle	Represents an advanced sacral decubitus ulcer involving muscle, commonly indicating need for debridement and flap closure.
`L89.154`	Pressure ulcer of sacral region with necrosis of bone	Indicates deep tissue loss potentially requiring extensive debridement and reconstruction; may complicate surgical planning.
`L89.159`	Pressure ulcer of sacral region, unspecified severity	Used when sacral pressure ulcer is documented but specific staging is not recorded; relevant to coding for surgical repair.
`L89.1530`	Pressure ulcer of sacral region with necrosis of muscle, stage 4 (if applicable per charting)	Specific staging supports medical necessity for operative debridement and graft/flap closure.
`L03.116`	Cellulitis of right lower limb (example of common surrounding infection codes)	Surrounding soft tissue infection may be present and influence timing and extent of surgical intervention.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`11042`	Debridement, subcutaneous tissue, first 20 sq cm or less	May be performed prior to or as part of surgical debridement for removal of devitalized subcutaneous tissue.
`13160`	Revision of skin graft; complicated, requiring extensive undermining or multiple revisions	May be used for subsequent revision when graft take is poor or when additional reconstruction is required.
`15730`	Muscle, myocutaneous, or fasciocutaneous flap with microvascular anastomosis	Used when a more complex flap reconstruction is required beyond simple grafting; relates as an alternative or adjunct for closure.
`15271`	Application of skin substitute graft to trunk, extensive >100 sq cm	May be used when biologic or synthetic grafts/skin substitutes are applied to large sacral wounds.
`12032`	Repair, intermediate, wound of trunk, 2.6 cm to 7.5 cm	May be used for smaller closure procedures or layered closure of donor sites or associated wounds.

CPT 15920: Sacrococcygeal Pressure Sore Debridement with Bone Excision

CPT-15922-SACROCOCCYGEAL-PRESSURE-ULCER-DEBRIDEMENT-FLAP-CLOSURE

CPT 15922: Sacrococcygeal Pressure Ulcer Debridement with Flap Closure

CPT-15931-SACRAL-PRESSURE-SORE-EXCISION-PRIMARY-CLOSURE

CPT 15931: Excision of Sacral Pressure Sore with Primary Closure

CPT-15933-PRESSURE-SORE-AND-SACRAL-BONE-EXCISION-WITH-CLOSURE

CPT 15933: Excision of Pressure Sore and Underlying Sacral Bone with Closure

CPT-15934-PRESSURE-SORE-EXCISION-FLAP-CLOSURE-SACRAL

CPT 15934: Excision of Sacral Pressure Sore with Flap Closure

CPT-15935-SACRAL-PRESSURE-ULCER-EXCISION-WITH-FLAP-CLOSURE

CPT 15935: Excision of Sacral Pressure Ulcer with Flap Closure

CPT-15937-SACRAL-PRESSURE-SORE-EXCISION-WITH-SKIN-MUSCLE-GRAFT

CPT 15937: Sacral Pressure Sore Excision with Skin/Muscle Graft

CPT-15940-HIP-PRESSURE-SORE-EXCISION-PRIMARY-CLOSURE

CPT 15940: Hip Pressure Sore Excision with Primary Closure

CPT-15941-PRESSURE-SORE-HIP-DEBRIDEMENT-BONE-REMOVAL-CLOSURE

CPT 15941: Excision of Hip Pressure Sore with Bone Removal and Closure

CPT-15944-HIP-PRESSURE-SORE-EXCISION-WITH-SKIN-FLAP-CLOSURE

CPT 15944: Hip Pressure Sore Excision with Skin Flap Closure

Showing 1–10 of 19

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when a substantially greater service was provided due to increased complexity of debridement or extensive reconstruction beyond typical expectations.
`23`	Unusual anesthesia	Use when anesthesia is medically contraindicated and heavy sedation or general anesthesia is not used, or when unusual circumstances require alternative anesthesia documentation.
`26`	Professional component	Use when reporting only the physician's professional component separate from technical facility services (rare for this operative code).
`50`	Bilateral procedure	Use when identical procedures are performed bilaterally (not commonly applicable for a single sacral pressure sore).
`51`	Multiple procedures	Use when this procedure is performed in the same operative session with other distinct surgical procedures; list primary and add `51` to secondary codes per payer rules.
`52`	Reduced services	Use when the service is partially reduced or not completed as originally planned (document reason for reduction).
`53`	Discontinued procedure	Use when the procedure is started but terminated due to extenuating circumstances; document reason for discontinuation.
`62`	Two surgeons	Use when two surgeons from different specialties work together substantially for the procedure (e.g., plastic surgeon assisting a general surgeon).
`66`	Surgical team (multiple surgeons)	Use when more than two surgeons are required and documented as a surgical team approach.
`78`	Unplanned return to OR	Use when the patient returns to the operating room for a related procedure during the global period due to complications.
`80`	Assistant surgeon	Use when an assistant surgeon is present and documentation supports assistant services.
`81`	Minimum assistant surgeon	Use when a minimal assistant is documented and meets payer criteria.
`82`	Assistant surgeon when qualified resident not available	Use when a qualified resident is not available and an assistant surgeon is required.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services for surgical procedures	Use when an advanced practice clinician performs or assists in portions of the procedure as permitted by payer policy.

Taxonomy Code	Specialty	Notes
207P00000X	Physical Medicine & Rehabilitation	Often involved in pre/postoperative rehabilitation and pressure offloading plans.
207L00000X	Surgery — General	Frequently performs initial debridement and wound management.
208C00000X	Surgery — Plastic	Commonly performs myocutaneous flap reconstruction or complex wound closure.
163W00000X	Wound Care	Specialist clinicians focused on chronic wound assessment and longitudinal care.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`L89.153`	Pressure ulcer of sacral region with necrosis of muscle	Represents an advanced sacral decubitus ulcer involving muscle, commonly indicating need for debridement and flap closure.
`L89.154`	Pressure ulcer of sacral region with necrosis of bone	Indicates deep tissue loss potentially requiring extensive debridement and reconstruction; may complicate surgical planning.
`L89.159`	Pressure ulcer of sacral region, unspecified severity	Used when sacral pressure ulcer is documented but specific staging is not recorded; relevant to coding for surgical repair.
`L89.1530`	Pressure ulcer of sacral region with necrosis of muscle, stage 4 (if applicable per charting)	Specific staging supports medical necessity for operative debridement and graft/flap closure.
`L03.116`	Cellulitis of right lower limb (example of common surrounding infection codes)	Surrounding soft tissue infection may be present and influence timing and extent of surgical intervention.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`11042`	Debridement, subcutaneous tissue, first 20 sq cm or less	May be performed prior to or as part of surgical debridement for removal of devitalized subcutaneous tissue.
`13160`	Revision of skin graft; complicated, requiring extensive undermining or multiple revisions	May be used for subsequent revision when graft take is poor or when additional reconstruction is required.
`15730`	Muscle, myocutaneous, or fasciocutaneous flap with microvascular anastomosis	Used when a more complex flap reconstruction is required beyond simple grafting; relates as an alternative or adjunct for closure.
`15271`	Application of skin substitute graft to trunk, extensive >100 sq cm	May be used when biologic or synthetic grafts/skin substitutes are applied to large sacral wounds.
`12032`	Repair, intermediate, wound of trunk, 2.6 cm to 7.5 cm	May be used for smaller closure procedures or layered closure of donor sites or associated wounds.

CPT 15920: Sacrococcygeal Pressure Sore Debridement with Bone Excision

CPT-15922-SACROCOCCYGEAL-PRESSURE-ULCER-DEBRIDEMENT-FLAP-CLOSURE

CPT 15922: Sacrococcygeal Pressure Ulcer Debridement with Flap Closure

CPT-15931-SACRAL-PRESSURE-SORE-EXCISION-PRIMARY-CLOSURE

CPT 15931: Excision of Sacral Pressure Sore with Primary Closure

CPT-15933-PRESSURE-SORE-AND-SACRAL-BONE-EXCISION-WITH-CLOSURE

CPT 15933: Excision of Pressure Sore and Underlying Sacral Bone with Closure

CPT-15934-PRESSURE-SORE-EXCISION-FLAP-CLOSURE-SACRAL

CPT 15934: Excision of Sacral Pressure Sore with Flap Closure

CPT-15935-SACRAL-PRESSURE-ULCER-EXCISION-WITH-FLAP-CLOSURE

CPT 15935: Excision of Sacral Pressure Ulcer with Flap Closure

CPT-15937-SACRAL-PRESSURE-SORE-EXCISION-WITH-SKIN-MUSCLE-GRAFT

CPT 15937: Sacral Pressure Sore Excision with Skin/Muscle Graft

CPT-15940-HIP-PRESSURE-SORE-EXCISION-PRIMARY-CLOSURE

CPT 15940: Hip Pressure Sore Excision with Primary Closure

CPT-15941-PRESSURE-SORE-HIP-DEBRIDEMENT-BONE-REMOVAL-CLOSURE

CPT 15941: Excision of Hip Pressure Sore with Bone Removal and Closure

CPT-15944-HIP-PRESSURE-SORE-EXCISION-WITH-SKIN-FLAP-CLOSURE

CPT 15944: Hip Pressure Sore Excision with Skin Flap Closure

Showing 1–10 of 19

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

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CPT 15936: Excision of Sacral Pressure Sore with Skin or Muscle Graft

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

CPT 15936: Excision of Sacral Pressure Sore with Skin or Muscle Graft

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Billing Code Overview

CPT 15936: Excision of Sacral Pressure Sore with Skin or Muscle Graft

Sign up for cpt 15936 policy alerts

Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What does CPT 15936 represent and who typically performs it?

Which modifiers are commonly relevant to reporting CPT 15936?

Are there related CPT codes I should consider when billing for sacral pressure sore procedures?

Which diagnosis codes are relevant to support medical necessity for CPT 15936?

What clinical steps and multidisciplinary care are described for a patient undergoing the procedure in CPT 15936?

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

What does CPT 15936 represent and who typically performs it?

Which modifiers are commonly relevant to reporting CPT 15936?

Are there related CPT codes I should consider when billing for sacral pressure sore procedures?

Which diagnosis codes are relevant to support medical necessity for CPT 15936?

What clinical steps and multidisciplinary care are described for a patient undergoing the procedure in CPT 15936?

References