Coding Ahead
CasePilot
Medical Coding Assistant
CaseConsultant
Instant Email Coding Consultant
Case2Code
Search and Code Lookup Tool
CareerCenter
Medical Coding Job Board
Log in Register free account

Need help choosing the right code?

Ask CasePilot about procedures, modifiers, bundling, and coding guidance.

Try CasePilot

Official Description

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)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

Epidermal autografts are specialized skin grafts that consist solely of the epidermis, the outermost layer of skin. These grafts are typically harvested from donor sites such as the thigh, buttocks, abdominal wall, or scalp. The procedure involves the careful preparation of the donor site, where a local anesthetic combined with epinephrine is injected into the subcutaneous tissue to minimize discomfort and control bleeding during the harvesting process. A dermatome, which is a surgical instrument designed for cutting skin, is then utilized to obtain the graft. The oscillating blade of the dermatome is meticulously adjusted to the appropriate depth to ensure that only the epidermis, with minimal or no dermis, is collected. The dermatome is moved in a continuous motion across the skin surface of the donor site, applying 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 wound bed of the recipient site and secured in position, 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 15115 is used for billing the first 100 square centimeters or less of grafting in adults or for 1% of total body surface area (TBSA) in infants and children, while CPT® Code 15116 is designated for each additional 100 square centimeters in adults or each additional 1% of TBSA in infants and children, or any part thereof.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure of epidermal autografting is indicated for various conditions that necessitate skin coverage and repair. These may include:

  • Burns: Severe burns that damage the epidermis and require skin grafting for healing.
  • Trauma: Skin loss due to traumatic injuries that necessitate reconstruction.
  • Chronic Wounds: Non-healing ulcers or wounds that fail to respond to conventional treatments.
  • Skin Cancer: Surgical excision of skin cancers that result in significant skin loss.

2. Procedure

The epidermal autografting procedure involves several critical steps to ensure successful grafting. These steps include:

  • Step 1: Preparation of the Donor Site - The donor site is selected, typically from areas such as the thigh, buttocks, abdominal wall, or scalp. The area is cleaned and prepared for the procedure. A local anesthetic, often combined with epinephrine, is injected into the subcutaneous tissue to minimize pain and control bleeding during the graft harvesting process.
  • Step 2: Harvesting the Graft - A dermatome is utilized to harvest the epidermis. The oscillating blade of the dermatome is adjusted to the appropriate depth to ensure that only the epidermis is collected, with minimal or no dermis. The dermatome is then moved in a continuous motion across the donor site, applying downward pressure to effectively harvest the graft.
  • Step 3: Preparing the Graft - Once harvested, the graft may be prepared for transfer to the recipient site. This preparation can include the use of a meshing device, which expands the surface area of the graft, allowing for better integration with the recipient site.
  • Step 4: Securing the Graft - The graft is placed over the prepared wound bed of the recipient site. It is secured in place using sutures, typically four corner sutures along with a running suture around the periphery. In some cases, staples or fibrin sealant may be used as alternatives for securing the graft.

3. Post-Procedure

After the epidermal autografting procedure, post-operative care is essential for optimal healing and recovery. The grafted area should be monitored for signs of infection, and appropriate wound care should be provided. Patients may be advised to keep the area clean and dry, and to follow specific instructions regarding activity restrictions to avoid dislodging the graft. Follow-up appointments are typically scheduled to assess the healing process and to address any complications that may arise. The expected recovery time can vary based on the size of the graft and the individual patient's healing response.

Short Descr EPDRM AGRFT F/S/N/H/F/G/M EA
Medium Descr EPIDERMAL AGRFT F/S/N/H/F/G/M/DGT EA 100 SQCM
Long Descr 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)
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) 1 - Co-surgeons could be paid, though supporting documentation is required...
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 2
CCS Clinical Classification 172 - Skin graft

This is an add-on code that must be used in conjunction with one of these primary codes.

15115 MPFS Status: Active Code APC T ASC A2 Illustration for Code 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
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.
GC This service has been performed in part by a resident under the direction of a teaching physician
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main 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.
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
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
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)
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.
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"