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A split-thickness autograft is a surgical procedure that involves the harvesting of skin from a donor site on the body to cover a defect or wound on the trunk, arms, or legs. This type of graft includes the entire epidermis, which is the outer layer of skin, and a portion of the dermis, the underlying layer that provides structure and support. The harvesting process typically utilizes a specialized instrument known as a dermatome, which allows for precise removal of the skin at a controlled depth. Common donor sites for split-thickness skin grafts (STSGs) include areas such as the thigh, buttocks, abdominal wall, or scalp, where sufficient skin can be obtained without compromising the donor site. During the procedure, the donor site is first treated with a local anesthetic, often combined with epinephrine to minimize bleeding during the grafting process. The dermatome is then maneuvered over the skin in a continuous motion, applying downward pressure to ensure an even cut. Once the graft is harvested, it may be prepared for transfer to the recipient site, which can involve techniques such as meshing to increase the graft's surface area and facilitate better adherence to the wound bed. The graft is then placed over the prepared wound site and secured in position, typically using sutures, which may include four corner sutures along with a running suture around the edges. In some cases, alternative methods such as staples or fibrin sealants may be employed to secure the graft. It is important to note that CPT® Code 15101 is used to report each additional 100 square centimeters of grafting performed on adults or each additional 1% of total body surface area (TBSA) for infants and children, following the initial coverage reported with CPT® Code 15100.
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The split-thickness autograft procedure is indicated for various conditions that result in skin loss or defects on the trunk, arms, or legs. These indications may include, but are not limited to:
The split-thickness autograft procedure involves several key steps to ensure successful grafting. First, the donor site is selected, typically from areas with sufficient skin, such as the thigh, buttocks, abdominal wall, or scalp. The area is then prepared, and a local anesthetic is administered, often combined with epinephrine to minimize bleeding during the procedure. Following this, the dermatome is set to the appropriate depth to harvest the graft, which includes the epidermis and a portion of the dermis. The surgeon uses the dermatome to make a continuous cut over the donor site, applying consistent downward pressure to achieve an even thickness of the graft. Once the graft is harvested, it is carefully prepared for transfer to the recipient site. This may involve the use of a meshing device, which expands the surface area of the graft, allowing it to cover a larger wound area and facilitating drainage of fluids. The graft is then placed over the prepared wound bed at the recipient site, ensuring proper alignment and coverage. To secure the graft in place, the surgeon typically uses sutures, which may include four corner sutures along with a running suture around the periphery. In some cases, staples or a fibrin sealant may be utilized as an alternative method of securing the graft. This meticulous process is crucial for promoting optimal healing and integration of the graft with the surrounding tissue.
After the split-thickness autograft procedure, post-operative care is essential for ensuring proper healing and minimizing complications. The grafted area is monitored for signs of infection, and the patient may be advised to keep the area clean and dry. Dressings are typically applied to protect the graft and may need to be changed regularly as directed by the healthcare provider. Patients are often instructed to avoid putting pressure on the grafted area to prevent dislodgment and to promote adherence of the graft to the underlying tissue. Recovery time can vary depending on the size and location of the graft, as well as the individual patient's healing response. Follow-up appointments are necessary to assess the healing process and to make any adjustments to the care plan as needed. It is important for patients to adhere to the post-operative instructions provided by their healthcare team to ensure the best possible outcome from the grafting procedure.
| Short Descr | SPLT AGRFT T/A/L EA ADDL 100 | Medium Descr | SPLT AGRFT T/A/L EA ADD 100 SQCM/EA 1% INFT/CHLD | Long Descr | 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) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | 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) | 1 - Statutory 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 | Items and Services Packaged into APC Rates | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5A - Ambulatory procedures - skin | MUE | 40 | CCS Clinical Classification | 172 - Skin graft |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 15100 | Changed Code for 2025 MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Illustration for Code Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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.) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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.) | CR | Catastrophe/disaster related | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GZ | Item or service expected to be denied as not reasonable and necessary | 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. | 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. | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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). | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | ET | Emergency services | GW | Service not related to the hospice patient's terminal condition | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2006-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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