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A full-thickness free skin graft is a surgical procedure in which a section of skin that includes all layers—epidermis, dermis, and subcutaneous tissue—is removed from one area of the body (the donor site) and transplanted to another area (the recipient site) to close a wound or skin defect. This type of graft is particularly useful for larger defects, as it provides a robust and durable coverage that promotes healing and minimizes complications. The trunk, which refers to the central part of the body excluding the head and limbs, is a common site for such grafts due to its relatively large surface area and the potential for significant skin defects. During the procedure, careful consideration is given to the characteristics of both the donor and recipient sites to ensure compatibility in terms of skin thickness, texture, pigmentation, and hair presence. The donor site is meticulously outlined, often slightly enlarged to accommodate for skin contracture that may occur post-harvest. Local anesthesia, often combined with epinephrine to reduce bleeding, is administered to the patient before the graft is harvested. The graft is then carefully excised using a scalpel, and the underlying fat is separated to ensure a clean graft. After the graft is placed on the defect, it is secured with sutures, and a layered dressing is applied to protect the area and promote healing. The procedure is coded as CPT® Code 15200 when the graft area is 20 square centimeters or less, with additional codes available for larger grafts.
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Full-thickness grafts are indicated for various conditions where skin coverage is necessary to promote healing and restore function. The following are specific indications for performing this procedure:
The procedure for harvesting and applying a full-thickness skin graft involves several critical steps, each designed to ensure the successful transfer of skin from the donor site to the recipient site.
After the procedure, the patient will require careful monitoring of the graft site to ensure proper healing. It is essential to keep the area clean and dry, and the layered dressing should remain intact for a specified period as directed by the healthcare provider. 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 sutures as needed. Any signs of infection, such as increased redness, swelling, or discharge, should be reported to the healthcare provider immediately. The expected recovery time may vary depending on the individual and the size of the graft, but adherence to post-operative care instructions is crucial for optimal outcomes.
| Short Descr | FTH/GFT FR TRNK 20 SQ CM/< | Medium Descr | FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 SQ CM/< | Long Descr | Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less | 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) | P5A - Ambulatory procedures - skin | MUE | 1 | CCS Clinical Classification | 172 - Skin graft |
This is a primary code that can be used with these additional add-on codes.
| 15201 | Addon Code MPFS Status: Active Code APC N ASC N1 Illustration for Code Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) |
| 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). | 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. | 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GA | Waiver of liability statement issued as required by payer policy, individual case | 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 | 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) | SG | Ambulatory surgical center (asc) facility service | 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 |
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| 2025-01-01 | Changed | Short Description punctuation changed. |
| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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