How To Use CPT Code 15121

CPT code 15121 describes the procedure of split-thickness autograft for various areas of the body, such as the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 15121?

CPT code 15121 is used to describe the procedure of split-thickness autograft for specific areas of the body. This procedure involves the transplantation of skin from one part of the patient’s body to another to provide closure for burns or wounds. The skin graft used in this procedure contains both the epidermis and dermis but not the full thickness of the skin. The thickness of the skin slice depends on the donor site and the patient’s needs.

2. Official Description

The official description of CPT code 15121 is: ‘Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure).’ This code should be used in conjunction with the primary code for the split-thickness autograft procedure.

3. Procedure

The procedure for CPT code 15121 involves the following steps:

1. A dermatome, a surgical instrument used for grafting, is used to harvest a thin slice of skin from the patient’s donor site.
2. The harvested skin, which is typically 0.01 to 0.015 inches in depth, is then transplanted from the donor site to the burn or wound site that requires closure.
3. The split-thickness autograft contains both the epidermis and dermis but not the full thickness of the skin.
4. The thickness of the skin slice depends on the specific needs of the patient and the donor site.

4. Qualifying circumstances

CPT code 15121 is used for split-thickness autograft procedures performed on specific areas of the body, including the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. This code is used for each additional 100 square cm or each additional 1% of body area of infants and children, or part thereof, in addition to the primary procedure. It is important to note that this code should be used in conjunction with the primary code for the split-thickness autograft.

5. When to use CPT code 15121

CPT code 15121 should be used when performing a split-thickness autograft procedure on the specified areas of the body. It is important to use this code in addition to the primary procedure code for the split-thickness autograft. This code should not be used for full-thickness grafts or for procedures performed on areas not specified in the code description.

6. Documentation requirements

To support a claim for CPT code 15121, the following documentation is required:

• Documentation of the primary procedure for the split-thickness autograft.
• Documentation of the specific areas of the body where the autograft was performed.
• Documentation of the size of the autograft, either in square centimeters or as a percentage of body area.
• Documentation of the donor site from which the skin was harvested.
• Documentation of the thickness of the skin slice used in the autograft.

7. Billing guidelines

When billing for CPT code 15121, it is important to follow these guidelines:

• Report CPT code 15121 in conjunction with the primary code for the split-thickness autograft procedure.
• Do not append modifier 50 to add-on codes when the procedure is performed bilaterally. Instead, report the add-on code twice.

8. Historical information

CPT code 15121 was added to the Current Procedural Terminology system on January 1, 1990. There have been some changes to the code description over the years, including updates to the areas of the body covered by the code.

9. Similar codes to CPT 15121

There are several similar codes to CPT code 15121, including:

• CPT 15120: Split-thickness autograft, 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 (List separately in addition to code for primary procedure).
• CPT 15122: Split-thickness autograft, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children (List separately in addition to code for primary procedure).
• CPT 15123: Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure).
• CPT 15124: Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure).
• CPT 15125: Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or 1% of body area of adults (List separately in addition to code for primary procedure).

9. Examples

1. A patient with extensive burns on their face and neck undergoes a split-thickness autograft procedure using CPT code 15121.
2. A child with a severe hand injury requires a split-thickness autograft on their fingers, which is reported using CPT code 15121.