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Official Description

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

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 15004 refers to the surgical preparation or creation of a recipient site through the excision of open wounds, burn eschar, or scars, which may include the underlying subcutaneous tissues. This procedure is particularly relevant for addressing scar contractures in sensitive areas such as the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. The process involves the physician excising the affected tissue to prepare a healthy vascular bed, which is essential for the successful placement of a skin graft. This preparation may also include simple debridement or the removal of granulation tissue to ensure that the site is optimal for grafting. The code specifically applies to the first 100 square centimeters or 1% of the body area in infants and children, making it crucial for pediatric cases where skin grafting is necessary to repair defects. For additional areas beyond the initial measurement, the use of CPT® Code 15005 is required, allowing for accurate reporting of the extent of the surgical preparation performed.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 15004 is indicated for various conditions that necessitate the surgical preparation of a recipient site for skin grafting. These indications include:

  • Open Wounds - Situations where there are significant open wounds that require surgical intervention to prepare for grafting.
  • Burn Eschar - Cases involving burn injuries where eschar (the dead tissue that forms over a burn) needs to be excised to facilitate healing and grafting.
  • Scars - The presence of existing scars that may cause functional or aesthetic issues, necessitating their removal or release to improve skin mobility.
  • Scar Contractures - Conditions where scars have contracted the surrounding skin, leading to restricted movement, particularly in sensitive areas such as the face and hands.

2. Procedure

The procedure for CPT® Code 15004 involves several critical steps to ensure the recipient site is adequately prepared for skin grafting. These steps include:

  • Excision of Open Wounds - The physician begins by carefully excising any open wounds present in the targeted area. This step is crucial to remove any necrotic or non-viable tissue that could impede the healing process.
  • Removal of Burn Eschar - If burn eschar is present, it is meticulously removed to expose healthy tissue beneath. This is essential for creating a suitable environment for grafting.
  • Scar Excision or Incisional Release - The physician may also excise existing scars or perform an incisional release of scar contractures. This involves making incisions to relieve tension and improve the skin's mobility in the affected area.
  • Debridement - Simple debridement may be performed to eliminate any remaining granulation tissue or debris, ensuring that the site is clean and ready for grafting.
  • Preparation of Vascular Bed - After the excision and debridement, the physician prepares a healthy bed of vascular tissue. This is critical for the successful integration of the skin graft.

3. Post-Procedure

Post-procedure care following the surgical preparation for skin grafting is essential for optimal recovery. Patients may require monitoring for signs of infection at the surgical site. Additionally, proper wound care instructions will be provided to ensure the area remains clean and protected. The physician may also schedule follow-up appointments to assess the healing process and determine the appropriate timing for the placement of the skin graft. Pain management strategies may be discussed, and patients should be advised on activity restrictions to promote healing and prevent complications.

Short Descr WOUND PREP F/N/HF/G
Medium Descr PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT
Long Descr 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
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 172 - Skin graft

This is a primary code that can be used with these additional add-on codes.

15005 Addon Code MPFS Status: Active Code APC N ASC N1 Illustration for Code 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; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
LT Left side (used to identify procedures performed on the left side of the body)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
GC This service has been performed in part by a resident under the direction of a teaching physician
RT Right side (used to identify procedures performed on the right side of the body)
KX Requirements specified in the medical policy have been met
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
E4 Lower right, eyelid
E2 Lower left, eyelid
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
CR Catastrophe/disaster related
GW Service not related to the hospice patient's terminal condition
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AF Specialty physician
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
E1 Upper left, eyelid
E3 Upper right, eyelid
ET Emergency services
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
GA Waiver of liability statement issued as required by payer policy, individual case
GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception
GJ "opt out" physician or practitioner emergency or urgent service
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
JZ Zero drug amount discarded/not administered to any patient
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
Date
Action
Notes
2011-01-01 Changed Short description changed. Guideline information changed.
2007-01-01 Added New code
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