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The procedure described by CPT® Code 15221 involves the harvesting of a full-thickness skin graft from a designated donor site, which may include areas such as the scalp, arms, and/or legs. A full-thickness graft is characterized by its inclusion of all layers of the skin, which encompasses the epidermis, dermis, and subcutaneous fat, along with associated blood vessels. This type of graft is typically utilized in surgical procedures to repair larger defects or wounds where a more robust skin coverage is required. Following the harvesting of the graft, the donor site is meticulously closed to promote healing and minimize scarring. The harvested graft is then positioned over the defect area, ensuring proper alignment and coverage. The edges of both the defect and the graft are secured in place using sutures, facilitating the integration of the graft into the surrounding tissue. It is important to note that CPT® Code 15221 is specifically used to report each additional 20 square centimeters, or part thereof, of the grafted area beyond the initial coverage provided by CPT® Code 15220, which accounts for the first 20 square centimeters of grafting on the scalp, arms, or legs.
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The procedure associated with CPT® Code 15221 is indicated for various conditions that necessitate the use of a full-thickness skin graft. These indications may include:
The procedure for CPT® Code 15221 involves several critical steps to ensure successful grafting. The first step is the identification and preparation of the donor site, where the full-thickness graft will be harvested. The physician carefully selects an area on the scalp, arms, or legs that is suitable for grafting, ensuring that it will provide adequate skin for the procedure. Once the donor site is prepared, the physician excises a full-thickness section of skin, which includes the epidermis, dermis, and subcutaneous fat. This excised graft is then meticulously handled to preserve its integrity, as it contains essential blood vessels that will aid in its survival once placed on the defect. After harvesting the graft, the donor site is closed using direct closure techniques, which may involve suturing the edges of the skin together to promote healing and minimize scarring. The next step involves positioning the harvested graft over the defect area that requires coverage. The physician ensures that the graft is properly aligned and adequately covers the defect. Finally, the edges of both the graft and the defect are secured in place with sutures, facilitating the integration of the graft into the surrounding tissue and promoting healing.
Post-procedure care following the application of a full-thickness graft is crucial for ensuring optimal healing and graft survival. Patients are typically advised to keep the grafted area clean and dry, and to follow specific wound care instructions provided by the physician. Monitoring for signs of infection, such as increased redness, swelling, or discharge, is essential. Patients may also be instructed to avoid strenuous activities that could stress the graft site during the initial healing phase. Follow-up appointments are necessary to assess the healing process and to determine if any additional interventions are required. The expected recovery time may vary depending on the size of the graft and the individual patient's healing response.
| Short Descr | FTH/GFT FR S/A/L EACH ADDL | Medium Descr | FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 SQ CM | Long Descr | Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 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 | 9 | CCS Clinical Classification | 172 - Skin graft |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 15220 | MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Illustration for Code Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | RT | Right side (used to identify procedures performed on the right side of the body) | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | 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 | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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 and Medium Descriptions 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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