CPT 15936Surgery

Exc sac pr ulc prep mus flap

CPT 15936 covers the surgical removal of a pressure ulcer (bedsore) over the sacrum (lower back/tailbone area) and closure of the wound using a muscle flap taken from nearby tissue. This is a major reconstructive procedure typically performed on patients with severe, deep pressure wounds that won't heal with conservative treatment.

Showing rates for

National Average

Base Medicare rate

$870.77

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

13.16

PE RVU (NF)

10.97

MP RVU

2.79

Total RVU

26.92

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document ulcer staging (Stage III/IV) with specific depth measurements and anatomical structures involved (muscle, bone, fascia) in operative report
Impact: Prevents medical necessity denials worth the full $870.77 reimbursement; required for LCD compliance in most jurisdictions
Separately report bone debridement (11044) if significant ostectomy is performed, using modifier 59 to bypass NCCI edits
Impact: Additional $150-300 reimbursement for documented bone work beyond routine ulcer excision
Use modifier 22 with detailed operative note when procedure time exceeds 3 hours or involves complex anatomy (prior surgery, radiation, extensive undermining >20cm)
Impact: Can increase reimbursement by $174-435 (20-50%) with proper documentation comparing to typical case
Verify prior authorization before surgery; most payers require pre-certification for this high-cost procedure with documented conservative treatment failure
Impact: Prevents $870.77 denial; appeals are difficult without prospective authorization
Do not separately bill skin grafts or simple flap closures included in 15936; the muscle/myocutaneous flap is comprehensive
Impact: Avoids unbundling denials and potential fraud allegations; NCCI bundling applies to 15933-15935, 14000-14302
Bill facility charges separately; this procedure qualifies for high DRG reimbursement (typically DRG 573-574) worth $8,000-15,000 to hospital
Impact: Ensures facility receives appropriate payment beyond professional fee; coordinate with hospital coding staff

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 15936 in 2025?

The 2025 Medicare national average reimbursement for CPT 15936 is $870.77 for both facility and non-facility settings. This is based on 26.92 total RVUs (13.16 work RVU, 10.97 PE RVU, 2.79 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 15936 and 15933-15935?

CPT 15936 specifically requires muscle or myocutaneous flap closure after sacral pressure ulcer excision, while 15933 involves primary closure only, 15934 uses a skin flap, and 15935 uses ostectomy with skin flap. Code 15936 is used for more complex cases requiring muscle tissue for adequate vascular coverage and defect filling.

Can CPT 15936 be billed bilaterally?

CPT 15936 typically applies to a single sacral ulcer and is not considered a bilateral procedure. If multiple distinct sacral ulcers are excised with separate muscle flaps during the same session, consider modifier 59 or report multiple units with documentation, though this is rare. Most payers will bundle multiple sacral ulcer closures into a single comprehensive code.

What diagnosis codes support medical necessity for CPT 15936?

Primary diagnosis codes include L89.153-L89.154 (Stage 3-4 sacral pressure ulcer), L89.156 (unstageable sacral ulcer), or L89.159 (unspecified stage). Secondary diagnoses should document underlying risk factors such as paraplegia (G82.20-G82.22), quadriplegia (G82.50-G82.54), diabetes with complications, or prolonged immobility to establish medical necessity.

Does CPT 15936 include bone debridement or should that be coded separately?

Routine removal of underlying bursa and minimal bone trimming is included in 15936. However, extensive ostectomy or debridement of infected bone (osteomyelitis) may be separately reportable using codes 11044 or 11047 with modifier 59, if documentation clearly supports work significantly beyond the typical ulcer excision and the bone work is extensive.

How long is the global period for CPT 15936?

CPT 15936 has a 90-day global surgical period. All routine postoperative care including dressing changes, suture removal, and follow-up visits within 90 days are included in the $870.77 reimbursement. Complications requiring return to the OR use modifier 78; unrelated E/M services require modifier 24.

What documentation is needed to bill modifier 22 with CPT 15936?

For modifier 22 with 15936, document specific factors increasing work by 20-50%: operative time significantly exceeding 2-3 hours, extensive undermining beyond 20cm, severe osteomyelitis requiring extensive bone resection, morbid obesity complicating access, prior radiation or failed flaps requiring complex revision, or unusual anatomical complexity. Include comparison to typical case, time differential, and additional resources required. Submit operative note with modifier 22 claim and request 20-50% payment increase based on documented additional work.