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The procedure described by CPT® Code 15241 involves the harvesting and application of a full-thickness skin graft, which includes all layers of the skin along with associated blood vessels. This type of graft is typically utilized to repair significant defects in various anatomical locations, including the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and feet. The process begins with the physician carefully excising a section of skin from a donor site, ensuring that the graft is of sufficient size and quality to effectively cover the defect. Following the harvesting of the graft, the donor site is closed directly, which may involve suturing to promote proper healing and minimize scarring. The harvested graft is then positioned over the defect area, where it is secured in place, often with sutures, to ensure proper adherence and integration with the surrounding tissue. It is important to note that this code is specifically used to report each additional 20 square centimeters of grafted area beyond the initial coverage provided by CPT® Code 15240, which addresses the primary procedure for grafting up to 20 square centimeters. Therefore, when multiple grafts or larger areas are involved, CPT® Code 15241 is utilized in conjunction with 15240 to accurately reflect the extent of the procedure performed.
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The procedure associated with CPT® Code 15241 is indicated for the repair of skin defects that require a full-thickness graft. These defects may arise from various conditions, including but not limited to:
The procedure for applying a full-thickness graft as described by CPT® Code 15241 involves several critical steps:
Post-procedure care following the application of a full-thickness graft involves monitoring the graft site for signs of healing and potential complications. Patients are typically advised to keep the area clean and dry, and to follow specific wound care instructions provided by the physician. It is essential to avoid any activities that may stress the graft or donor site during the initial healing phase. Follow-up appointments are necessary to assess the graft's viability and to manage any issues that may arise, such as infection or graft failure. The expected recovery time may vary depending on the size and location of the graft, as well as the individual patient's healing response.
| Short Descr | FTH/GFT F/C/C/M/N/A/G/H/F EA | Medium Descr | FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA ADDL | Long Descr | Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 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.
| 15240 | MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Illustration for Code Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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. | 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. | 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 | F6 | Right hand, second digit | 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 | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | T9 | Right foot, fifth digit | TA | Left foot, great toe | 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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