CPT 15946Surgery

Exc isch pr ulc prep mus flp

CPT 15946 covers the surgical removal of a pressure sore (bedsore) over the sitting bone area, including preparation or advancement of muscle tissue to fill the wound. This is a major reconstructive procedure typically performed on patients with severe, deep pressure ulcers that have not healed with conservative treatment.

Showing rates for

National Average

Base Medicare rate

$1,565.57

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

24.12

PE RVU (NF)

19.53

MP RVU

4.75

Total RVU

48.4

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

NCCI bundling edits

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Billing tips

Document exact ulcer staging (Stage III or IV), dimensions in centimeters, and depth to muscle/bone in operative report
Impact: Prevents medical necessity denials that can result in $1565.57 loss; Stage II or superficial ulcers do not support this code
Clearly describe the specific muscle flap technique used (gluteus maximus rotation, advancement, V-Y advancement) with anatomical detail
Impact: Differentiates from simpler closure codes (15940-15945) which reimburse $400-800 less; ensures appropriate higher-level payment
Bill facility and non-facility settings correctly; this code has identical rates ($1565.57) but verify LCD coverage for ASC settings
Impact: Many Medicare contractors deny ASC claims for this code due to complexity requirements; hospital setting ensures payment
When multiple ulcers are treated, bill primary ulcer as 15946 and additional ulcers at different sites with appropriate codes plus modifier 59
Impact: Prevents bundling; can add $1000-3000 in additional revenue per separate anatomical site
Verify prior authorization requirements before surgery; most payers require pre-certification for this high-RVU procedure
Impact: Prevents retrospective denial of entire $1565.57 claim; authorization typically required 7-14 days pre-procedure
Report separately billable services like debridement if performed at previous session; do not report 11042-11047 on same date as 15946
Impact: Debridement codes are bundled into 15946 by NCCI; billing separately risks $100-300 recoupment plus audit flags

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 15946 in 2025?

The 2025 Medicare national average reimbursement for CPT 15946 is $1565.57 for both facility and non-facility settings, based on 48.4 total RVUs and the 2025 conversion factor of 32.3465.

What is the difference between CPT 15946 and 15945?

CPT 15946 includes muscle or myocutaneous flap preparation and advancement, while 15945 involves skin flap closure only. Code 15946 represents more complex reconstruction requiring muscle mobilization and reimburses approximately $400-500 more than 15945.

Can CPT 15946 be billed with debridement codes on the same date?

No, debridement codes (11042-11047) are bundled into CPT 15946 per NCCI edits and cannot be separately billed on the same date of service for the same anatomical site. The debridement is considered part of the excision procedure.

Does CPT 15946 require prior authorization from Medicare?

While original Medicare does not universally require prior authorization, many Medicare Advantage plans do require it for this high-cost procedure. Additionally, some state Medicaid programs and private insurers routinely require pre-certification for pressure ulcer reconstruction.

How many RVUs is CPT code 15946 worth?

CPT 15946 has a total of 48.4 RVUs for 2025, consisting of 24.12 work RVUs, 19.53 practice expense RVUs, and 4.75 malpractice RVUs, making it a high-value surgical procedure code.

What documentation is needed to support medical necessity for CPT 15946?

Documentation must include pressure ulcer staging (Stage III or IV), failed conservative treatment for at least 30 days, wound measurements, nutritional assessment, pressure relief interventions attempted, and evidence that the ulcer extends to muscle or bone requiring flap reconstruction.

Can CPT 15946 be billed bilaterally for pressure ulcers on both ischial tuberosities?

Yes, when bilateral ischial pressure ulcers are excised and reconstructed with muscle flaps during the same operative session, append modifier 50 for bilateral procedure, which typically increases reimbursement to 150% of the base rate ($2348.36 total) when properly documented.