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Epidermal autografts are specialized surgical procedures that involve the transplantation of skin tissue, specifically the epidermis, from one area of the body to another. This type of graft is particularly relevant for reconstructive purposes, especially in cases where the skin has been damaged due to injury, surgery, or disease. The procedure is commonly performed on sensitive areas such as the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. The harvesting of the graft typically occurs from donor sites like the thigh, buttocks, abdominal wall, or scalp, where the skin can be safely removed without significant cosmetic impact. During the procedure, local anesthesia is administered to the donor site to minimize discomfort, and epinephrine may be used to control bleeding. The use of a dermatome, a specialized surgical instrument, allows for precise harvesting of the epidermis while preserving the underlying dermis as much as possible. This technique ensures that the graft is thin and suitable for successful integration at the recipient site. Once harvested, the graft may be prepared using a meshing device to increase its surface area, facilitating better adherence and healing when placed over the wound bed. The graft is then secured in place using sutures, staples, or fibrin sealant, ensuring stability during the healing process. This procedure is coded under CPT® Code 15115 for the first 100 square centimeters or less in adults or for 1% of total body surface area in infants and children, with additional grafting procedures coded separately.
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The procedure of epidermal autograft is indicated for various conditions that necessitate skin replacement or reconstruction. These include:
The procedure for performing an epidermal autograft involves several critical steps to ensure successful grafting and healing. Each step is essential for the overall outcome of the procedure.
After the epidermal autograft procedure, careful post-operative care is essential for optimal healing. The recipient site should be monitored for signs of infection, and the graft should be kept clean and protected. Patients may be advised to avoid strenuous activities that could disrupt the graft. Follow-up appointments are necessary to assess the healing process and to remove any sutures or staples if used. The expected recovery time can vary depending on the size and location of the graft, as well as the individual’s overall health. Proper care and monitoring will help ensure the graft integrates well and promotes healing of the underlying tissue.
| Short Descr | EPDRM AGRFT F/S/N/H/F/G/M 1 | Medium Descr | EPIDERMAL AGRFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM/< | Long Descr | Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; 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.
| 15116 | Addon Code MPFS Status: Active Code APC N ASC N1 Illustration for Code Epidermal 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) |
| 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.) | 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). | 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. | 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. | 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. | 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.) | 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 | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | QS | Monitored anesthesia care service | QX | Crna service: with medical direction by a physician | 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. |
| 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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