Dermatology Coding Alert

Question: We have a trauma victim who requires a skin graft. The donor site is the right thigh, and the recipient site is the abdomen. The operative note describes the graft as a "split-thickness skin graft, size 25 x 18 cm." Should I report 15000?


Michigan Subscriber

Answer: Your code choice for split-thickness grafts depends on the amount of square centimeters involved. In this case, you would multiply 25 times 18 to determine the full area -- which equals 450 square cm.

For the graft harvesting -- assuming, of course, that you have the appropriate documentation -- you would report 15000 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture; first 100 sq cm or one percent of body area of infants and children) once and +15001 (... each additional 100 sq cm or each additional one percent of body area of infants and children [list separately in addition to code for primary procedure]) three times.

To describe the grafting, you'll report one unit of 15100 (Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children [except 15050]) and three units of +15101 (... each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof [list separately in addition to code for primary procedure]).