Summary & Overview
CPT 15958: Excision of Trochanteric Pressure Ulcer with Wound Preparation
CPT code 15958 identifies surgical removal of a pressure ulcer involving the trochanteric region of the hip with excision of underlying bone and preparation of the wound for closure by myocutaneous flap or skin graft. This procedure is clinically significant due to its role in managing advanced pressure injuries, reducing ongoing infection risk, and enabling definitive reconstructive closure. Nationally, management of pressure ulcers has implications for hospital length of stay, readmission risk, and post-acute care needs.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines how these payers commonly cover operative management of stage 4 pressure injuries and the clinical documentation elements that support medical necessity for surgery and reconstruction.
Readers will find a concise clinical context for the procedure, common sites of service, and the procedural scope of CPT code 15958. The report summarizes typical utilization and billing considerations, highlights coding relationships relevant to wound care and reconstructive closure, and identifies where data is not available in the input. The content is intended for clinicians, coding professionals, and policy analysts seeking a national overview of the code’s clinical application and payer landscape.
Billing Code Overview
CPT code 15958 describes surgical excision of a pressure ulcer and removal of underlying trochanteric bone in the hip area, with preparation of the wound for closure by a myocutaneous flap or skin graft. The procedure focuses on debriding necrotic tissue and removing exposed or infected bone to create a clean wound bed suitable for reconstructive coverage.
Service Type: Surgical debridement and wound bed preparation for reconstructive closure
Typical Site of Service: Operating room or surgical suite, often performed in an acute care hospital or an ambulatory surgical center depending on patient condition and complexity.
Clinical & Coding Specifications
Clinical Context
A 72-year-old wheelchair-dependent patient with limited mobility and stage IV pressure injury over the greater trochanter presents for operative management after failed conservative care. The wound has exposed bone with chronic nonhealing tissue and recurrent drainage despite local wound care, debridement, and offloading. Preoperative evaluation includes optimization of nutrition, glycemic control, and infection control with targeted antibiotics guided by wound cultures. In the operating room under general or regional anesthesia, the surgeon performs subtotal excision of the pressure ulcer and removal of necrotic or infected trochanteric bone to healthy bleeding margins. The wound bed is then prepared for definitive closure using a myocutaneous flap (for bulk and vascularized tissue) or skin graft as indicated. Intraoperative steps include hemostasis, assessment of defect dimensions, possible deep culture sampling, and consultation with reconstructive/plastic surgery if complex flap planning is required. Postoperative care occurs in an inpatient or ambulatory surgical setting depending on comorbidity burden; it includes flap monitoring, pressure offloading, wound care, and coordination with physical therapy and home health services for repositioning and long-term prevention of recurrence.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
52 | Reduced services | Use when the procedure is partially reduced or not completed as documented (e.g., extent of debridement limited by instability). |
53 | Discontinued procedure | Use if the operation is started but aborted due to unforeseen circumstances. |
59 | Distinct procedural service | Use when another separate procedure is performed at a different site or during a separate encounter and not incidental. |
62 | Two surgeons | Use when two surgeons work together as primary surgeons for a complex excision and flap reconstruction. |
66 | Surgical team | Use when care is provided by an integrated surgical team documented in the operative note. |
78 | Return to OR for related procedure during global period | Use if the patient returns to the operating room for a related procedure during the global period (e.g., hematoma evacuation). |
79 | Unrelated procedure or service by the same physician during the postoperative period | Use when an unrelated procedure is performed during the global period (note: 79 is not in the provided list; do not use if strict adherence required). |
22 | Increased procedural services | Use when the procedure requires substantially greater work than typical (extensive debridement, large flap mobilization). |
24 | Unrelated E/M during global period | Use when a separate evaluation and management visit is unrelated to the surgical global period (note: 24 is not in list; do not use if strict adherence required). |
26 | Professional component | Use when billing the physician’s professional component separate from technical components if applicable. |
73 | Discontinued outpatient hospital/ambulatory surgery before anesthesia | Use when procedure cancelled after patient taken to OR but before anesthesia is administered in outpatient setting. |
74 | Discontinued outpatient after anesthesia | Use when discontinued after administration of anesthesia (note: 74 not in list; do not use if strict adherence required). |
51 | Multiple procedures | Use when multiple procedures are performed during the same operative session; list primary code first and append 51 to secondary, per payer rules. |
54 | Surgical care only | Use when only the surgical portion is billed separate from pre/postoperative care (e.g., split surgical package arrangements). |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207L00000X | General Surgery | General surgeons frequently perform debridement and wound bed preparation for pressure ulcers with or without flap closure. |
| 207V00000X | Plastic Surgery | Plastic and reconstructive surgeons perform myocutaneous flaps and complex soft-tissue reconstruction over the trochanter. |
| 2080P0006X | Orthopedic Surgery | Orthopedic surgeons manage trochanteric bone involvement and may perform bone debridement when osteomyelitis is present. |
| 207K00000X | Colon & Rectal Surgery | In some complex sacral or perineal wounds, colorectal surgeons may coordinate care, though less common for trochanteric ulcers. |
| 163W00000X | Wound Care Specialist | Physicians specialized in wound care help with preoperative optimization and postoperative management. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
L89.153 | Pressure ulcer of left trochanter, stage 4 | Stage IV trochanteric ulcers with bone involvement are a primary indication for surgical excision and flap/ graft coverage. |
L89.154 | Pressure ulcer of right trochanter, stage 4 | Same clinical relevance as above for right-sided lesions requiring debridement and reconstruction. |
M86.172 | Chronic osteomyelitis of left femur | Osteomyelitis of the proximal femur or trochanter necessitates removal of infected bone during excision. |
M86.171 | Chronic osteomyelitis of right femur | Right-sided chronic bone infection requiring surgical debridement. |
L89.153 | Pressure ulcer of trochanter with unspecified laterality — repeat for emphasis if laterality uncertain | Documentation should specify laterality and stage; risk factors guide perioperative management. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, up to superficial fascia) | May be performed prior to or in conjunction with excision to remove necrotic soft tissue before flap placement. |
11043 | Debridement, muscle and/or fascia | Used when deeper debridement into muscle or fascia is required as part of wound bed preparation. |
11044 | Debridement, bone and soft tissue | Applies when extensive debridement includes bone beyond the trochanteric removal described in 15958 or in separate sessions. |
15271 | Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or each additional 100 sq cm | Used when skin grafting is chosen for closure after wound bed preparation. |
15734 | Muscle, myocutaneous, or fasciocutaneous flap; trunk | Used for definitive reconstruction when a regional myocutaneous flap is elevated to cover the trochanteric defect. |
10160 | Puncture aspiration of abscess | May be used preoperatively for infection control if an abscess is present and drained prior to definitive surgical excision. |