Orthopedic Coding Alert

Tip: Confirm ulcer location and any procedures.

Pressure sores or ulcers are a common finding in any patient who has been bedridden for long. You may often find your surgeon treating a pressure ulcer in a patient who has had a fractured femur and has been advised immobilization for six to eight weeks in bed. Reporting pressure ulcers is simple, provided your surgeon clearly documents the exact location of the ulcer and the treatment used for the ulcer.

Primary Suture Repair: Look at the Location of Ulcer

Your surgeon may just close the ulcer wound using a primary suture. This is usually the case when your surgeon is treating smaller pressure ulcers. In these situations, you confirm the location of the pressure ulcer and report code 15931 (Excision, sacral pressure ulcer, with primary suture), 15940 (Excision, ischial pressure ulcer, with primary suture), or 15950 (Excision, trochanteric pressure ulcer, with primary suture) for ulcers on the sacrum, ishium, or troachanter, respectively.

Confirm Additional Ostectomy

To treat a deeper ulcer, your surgeon may go in for an ostectomy in addition to the primary suture. Your surgeon may do a complete excision of the sacral pressure ulcer including the entire bursa and/or ostectomy. In this case again depending upon the location of the pressure ulcer, you select among the following codes:

• 15920 (Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture)
• 15933 (Excision, sacral pressure ulcer, with primary suture; with ostectomy)
• 15941 (Excision, ischial pressure ulcer, with primary suture; with ostectomy [ischiectomy])
• 15951 (Excision, trochanteric pressure ulcer, with primary suture; with ostectomy)