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Official Description

Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

An epidermal autograft is a surgical procedure that involves the harvesting of the epidermis, the outermost layer of skin, to cover a defect located on the trunk, arms, or legs. This type of graft is specifically designed to restore the skin's integrity in areas where it has been damaged or lost due to injury, surgery, or other medical conditions. The procedure is particularly relevant for infants and children, as it allows for the coverage of wounds that may encompass up to 1% of their total body surface area (TBSA). The grafting process begins with the selection of a donor site, which is typically chosen from areas such as the thigh, buttocks, abdominal wall, or scalp. To ensure patient comfort and minimize bleeding during the procedure, a local anesthetic combined with epinephrine is injected into the subcutaneous tissue at the donor site. The use of a dermatome, a specialized surgical instrument, allows for the precise harvesting of the epidermis at a controlled depth, ensuring that minimal dermal tissue is included. The dermatome is operated in a continuous motion with downward pressure to effectively remove the graft. Once harvested, the graft may be prepared for transfer to the recipient site, which can involve techniques such as meshing to increase the graft's surface area. Finally, the graft is placed over the wound bed and secured using sutures, staples, or fibrin sealant, ensuring proper adherence and promoting healing.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure of epidermal autograft is indicated for the following conditions:

  • Skin Defects The procedure is performed to cover skin defects resulting from trauma, burns, or surgical excisions.
  • Wound Healing It is indicated for enhancing wound healing in areas where the skin has been compromised.
  • Skin Loss The procedure is suitable for patients experiencing skin loss due to various medical conditions or injuries.

2. Procedure

The epidermal autograft procedure involves several critical steps to ensure successful grafting and healing:

  • Step 1: Donor Site Preparation The first step involves selecting an appropriate donor site, which is typically the thigh, buttocks, abdominal wall, or scalp. The area is cleaned and prepared to minimize the risk of infection.
  • Step 2: Anesthesia Administration A local anesthetic, along with epinephrine, is injected into the subcutaneous tissue at the donor site. This combination helps to control bleeding and provides pain relief during the harvesting process.
  • Step 3: Graft Harvesting Using a dermatome, the surgeon adjusts the oscillating blade to the correct depth to harvest only the epidermis, ensuring minimal dermal tissue is included. The dermatome is then advanced over the skin surface in a continuous motion, applying downward pressure to effectively remove the graft.
  • Step 4: Graft Preparation After harvesting, the graft is prepared for transfer to the recipient site. This may involve the use of a meshing device to expand the surface area of the graft, allowing for better adherence and coverage of the wound.
  • Step 5: Graft Placement The prepared graft is placed over the wound bed of the recipient site. It is then secured using sutures, typically four corner sutures with a running suture around the periphery. Alternatively, staples or fibrin sealant may be utilized to ensure the graft remains in place.

3. Post-Procedure

Post-procedure care for patients undergoing an epidermal autograft includes monitoring the graft site for signs of infection and ensuring proper healing. Patients are typically advised to keep the area clean and dry, and to follow specific instructions regarding dressing changes. The healing process may vary depending on the size and location of the graft, as well as the patient's overall health. Regular follow-up appointments are essential to assess the graft's integration and to manage any complications that may arise during the recovery period.

Short Descr EPIDRM AGRFT T/A/L 1ST 100
Medium Descr EPIDRM AGRFT T/A/L 1ST 100 SQCM/1% INFT/CHLD
Long Descr Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard 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 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.

15111 Addon Code MPFS Status: Active Code APC N ASC N1 Illustration for Code Epidermal 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)
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)
RT Right side (used to identify procedures performed on the right side of the body)
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.
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).
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.
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.
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.)
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.)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
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
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2025-01-01 Changed Short and Medium Descriptions changed.
2013-01-01 Changed Medium Descriptor changed.
2007-01-01 Changed Code description changed.
2006-01-01 Added First appearance in code book in 2006.
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