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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 donor site is carefully selected based on the characteristics of the recipient site, ensuring that factors such as thickness, texture, pigmentation, and hair presence are matched as closely as possible to achieve optimal cosmetic and functional results. During the procedure, the surgeon outlines the area of skin to be harvested, slightly enlarging it to accommodate for skin contracture that may occur post-surgery. Local anesthesia, often combined with epinephrine to reduce bleeding, is administered to the donor site. The graft is then excised using a scalpel, with careful attention to separate the graft from the underlying subcutaneous fat. After the graft is harvested, the donor site is closed with sutures, and any excess fat is removed to ensure a clean closure. The harvested graft is then placed over the defect at the recipient site and secured in place with sutures. A layered dressing is applied to protect the graft and promote healing, which typically includes a nonadherent layer, a bulky gauze layer, a compression layer, and an anti-shear layer to minimize movement and friction. This procedure is coded with CPT® Code 15201 when reporting each additional 20 square centimeters or part thereof, in conjunction with the primary procedure code 15200, which covers the initial 20 square centimeters of grafting on the trunk.
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The full-thickness graft procedure is indicated for various conditions where skin coverage is necessary. These may include:
The procedure for a full-thickness free skin graft involves several critical steps, each essential for successful grafting and healing.
Post-procedure care is essential for the successful healing of the graft. Patients are typically monitored for signs of infection or graft failure. The dressing should remain intact and dry, and patients are advised to avoid any activities that may stress the graft site. Follow-up appointments are necessary to assess the healing process and to remove sutures as needed. Patients may also receive instructions on how to care for the graft site, including keeping it clean and protected. The expected recovery time can vary depending on the size and location of the graft, but patients should be prepared for a healing period that may last several weeks.
| Short Descr | FTH/GFT FR TRNK EACH ADDL | Medium Descr | FTH/GFT FR W/DIR CLSR TRUNK EA ADDL 20 SQ CM | Long Descr | 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) | 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) | P5A - Ambulatory procedures - skin | MUE | 7 | CCS Clinical Classification | 172 - Skin graft |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 15200 | MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Illustration for Code Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less |
| 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. | 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. | 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.) | E2 | Lower left, eyelid | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | 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 and Medium Descriptions spelling/punctuation changed. |
| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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