“What code would you recommend for the excision of a pressure ulcer? Here is an excerpt from the operative report: “Attention was directed to the left plantar medical foot at the level of the arch where an approximately 3 cm round chronic ulceration with underlying bursa formation was noted. At this time, an elliptical incision was made in a 3:1 fashion running in line with the foot from toe to heel. This incision was deepened through subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures. At this time, dissection scissors were utilized in order to remove the chronic ulceration with underlying bursa. The skin margins were then separated in order to free up and allow for skin closure.”
The most appropriate CPT code to bill for the excision of a pressure ulcer is CPT code 15999 which is defined as: Unlisted procedure, excision pressure ulcer. The reason that this is the most appropriate CPT code to bill is based upon the fact that when the CPT Manual is accessed and you locate within the Surgery/Integumentary System Chapter “Pressure Ulcers (Decubitus Ulcers), the more specific codes within the same series of CPT code 15999 (15920-15958), do not apply to podiatry as they are for wound care around the lower back, thighs, and hips. Therefore CPT code 15999 is the way to go.
I do have a question, though. When I read through the operative report, is an ulcer on the “left medial foot at the level of the arch where an approximately 3 cm round chronic ulceration with underlying bursa formation noted” truly a pressure ulcer? Perhaps it is just me, but this appears to be a non-pressure ulcer. The most appropriate CPT code to bill for the excision of a non-pressure ulcer would entail the use of the 1142_ series of CPT codes based upon the appropriate size and area involved. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins and includes simple (non-layered) closure when performed. The CPT Manual states: The correct CPT code is determined by measuring the greatest clinical diameter of the lesion plus that margin required for complete excision. Lesion diameter plus the most narrow margins required equals the excised diameter.
I have an issue with this scenario. Excision is defined as a full-thickness removal of a lesion through the dermis. When the operative report in the post is accessed, the procedure is deepened through the dermis AND through the subcutaneous tissue. Not only is the ulcer removed, but so is the underlying bursa. This changes everything. The excision of this ulcer appears to be an integral part of the procedure for the removal of the underling bursa. If the end result was the removal of the bursa, based upon this premise, I feel that the most appropriate CPT code to bill is CPT code 28090 which is defined as: Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (e.g. cyst or ganglion); foot.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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