How To Use CPT Code 15004

CPT 15004 refers to the surgical preparation of a recipient site for skin grafting, specifically for open wounds, burn eschar, or scar contracture on various body parts. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 15004.

1. What is CPT 15004?

CPT 15004 is a medical procedure code used to describe the surgical preparation or creation of a recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture on specific body parts. This code is applicable for the first 100 sq cm or 1% of body area of infants and children. The procedure is essential for repairing areas of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits.

2. 15004 CPT code description

The official description of CPT code 15004 is: “Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.”

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider marks the open wound, burn eschar, or scar to be repaired.
3. The provider incises the site, along with the subcutaneous tissue, which is the deepest layer of skin.
4. The wound may be further scrubbed to achieve a healthy tissue bed for immediate or future skin grafting.
5. The provider ensures that the bleeding stops after the procedure.
6. The area is prepared for skin grafting, completing the surgical preparation of the recipient site.

4. Qualifying circumstances

Patients eligible to receive CPT code 15004 services are those with open wounds, burn eschar, or scar contracture on the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits. The code is applicable for the first 100 sq cm or 1% of body area of infants and children. It is essential for the patient to have a need for skin grafting to repair the affected area.

5. When to use CPT code 15004

It is appropriate to bill the 15004 CPT code when a provider performs surgical preparation of a recipient site for skin grafting on a patient with open wounds, burn eschar, or scar contracture on the specified body parts. The code should be used for the first 100 sq cm or 1% of body area of infants and children.

6. Documentation requirements

To support a claim for CPT 15004, the following information needs to be documented:

• Patient’s medical history and physical examination findings
• Indication for the surgical preparation of the recipient site
• Location and size of the open wound, burn eschar, or scar contracture
• Details of the surgical procedure, including anesthesia, incision, and wound preparation
• Postoperative care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 15004, it is essential to follow the appropriate guidelines and rules. Ensure that the patient meets the qualifying circumstances for the procedure and that the documentation requirements are met. Additionally, be aware of any related codes, such as +15005 for each additional 100 cm2, or part thereof, in patients 10 and older, or each additional 1 percent of body area of infants and children under 10.

8. Historical information

CPT 15004 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates since its addition.

9. Similar codes to CPT 15004

Five similar codes to CPT 15004 differentiate based on the site and amount of body area involved. These codes include:

• CPT 15002: Surgical preparation for a smaller area of the body
• CPT 15003: Surgical preparation for a larger area of the body
• CPT 15005: Additional 100 cm2 or part thereof for patients 10 and older, or each additional 1 percent of body area of infants and children under 10
• CPT 15040: Harvesting of a skin graft from a donor site
• CPT 15050: Skin grafting procedure

10. Examples

1. A child with a burn eschar on the face requiring surgical preparation for skin grafting
2. An infant with an open wound on the scalp needing recipient site preparation
3. A patient with scar contracture on the neck requiring incisional release and surgical preparation
4. A child with multiple digit contractures needing surgical preparation for skin grafting
5. A patient with an open wound on the hand requiring recipient site preparation
6. An infant with a burn eschar on the foot needing surgical preparation for skin grafting
7. A child with a scar contracture on the ear requiring incisional release and surgical preparation
8. A patient with an open wound on the genitalia needing recipient site preparation
9. An infant with a burn eschar on the orbit requiring surgical preparation for skin grafting
10. A child with a scar contracture on the mouth needing incisional release and surgical preparation