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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 composed solely of epidermal tissue, which is crucial for promoting healing and restoring the integrity of the skin in areas where it has been damaged or lost. Common sites for harvesting the epidermal autograft include the thigh, buttocks, abdominal wall, or scalp, where sufficient skin can be obtained without compromising the donor site. During the procedure, local anesthetic and epinephrine are injected into the subcutaneous tissue at the donor site to minimize pain and control bleeding, ensuring a safer and more comfortable experience for the patient. The dermatome, a specialized surgical instrument, is then utilized to precisely remove the epidermis at a controlled depth, ensuring that only the epidermis is harvested, with minimal or no dermal tissue included. The dermatome is operated in a continuous motion with downward pressure to effectively harvest the graft. Once harvested, the graft is prepared for transfer to the recipient site, which may involve the use of a meshing device to increase the surface area of the graft, facilitating better integration and healing. The graft is then placed over the prepared wound bed of the recipient site and secured in place, typically using four corner sutures along with a running suture around the periphery. In some cases, alternative methods such as staples or fibrin sealant may be employed for securing the graft. It is important to note that CPT® Code 15110 is used for the first 100 square centimeters or less in adults or for 1% of total body surface area (TBSA) in infants and children, while CPT® Code 15111 is designated for each additional 100 square centimeters in adults or each additional 1% of TBSA in infants and children, or part thereof.
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The epidermal autograft procedure is indicated for various conditions that result in skin loss or defects on the trunk, arms, or legs. These indications may include:
The procedure for performing an epidermal autograft involves several critical steps to ensure successful grafting. First, the surgeon selects an appropriate donor site, typically located on the thigh, buttocks, abdominal wall, or scalp, where healthy skin can be harvested. Once the donor site is identified, local anesthetic and epinephrine are injected into the subcutaneous tissue to minimize discomfort and control bleeding during the procedure. Following this, the dermatome is adjusted to the correct depth to ensure that only the epidermis is harvested, avoiding any dermal tissue. The surgeon then operates the dermatome in a continuous motion over the skin surface of the donor site, applying downward pressure to effectively remove the epidermis. After harvesting, the graft is prepared for transfer, which may involve the use of a meshing device to expand its surface area, allowing for better adherence and healing when placed on the recipient site. The graft is then positioned over the prepared wound bed, ensuring proper alignment and coverage. To secure the graft in place, the surgeon typically uses four corner sutures along with a running suture around the periphery of the graft. In some cases, alternative fixation methods such as staples or fibrin sealant may be utilized to ensure the graft remains securely attached during the healing process.
After the epidermal autograft procedure, post-operative care is essential for promoting healing and preventing complications. The patient is typically monitored for any signs of infection or graft failure. It is important to keep the graft site clean and dry, and the surgeon may provide specific instructions regarding wound care, including how to change dressings and when to follow up for evaluation. Patients may also be advised to avoid strenuous activities that could stress the graft site during the initial healing phase. The expected recovery time can vary depending on the size of the graft and the individual’s overall health, but close follow-up is necessary to assess the integration of the graft and to manage any potential complications that may arise.
| Short Descr | EPIDRM AGRFT T/A/L EA ADDL | Medium Descr | EPDRM AGRFT T/A/L EA ADD 100 SQCM/EA 1%INFT/CHLD | Long Descr | 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) | 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) | P1G - Major procedure - Other | MUE | 5 | CCS Clinical Classification | 172 - Skin graft |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 15110 | MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Illustration for Code Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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. | 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. | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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.) | 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.) | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | 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 | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | 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). | 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) | 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 |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2006-01-01 | Added | First appearance in code book in 2006. |
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