Split-Thickness Skin Graft (STSG)
1510015101wRVU: 1.68 — STSG, trunk/arm/leg, each additional 100 sq cm beyond first (true CPT add-on to 15100; 1.68 wRVU)15120wRVU: 9.9 — STSG, face/scalp/eyelids/mouth/neck/ears/orbits/genitalia/hands/feet/multiple digits, first 100 sq cm (standalone primary code — NOT an add-on to 15100; use instead of 15100 for these anatomic sites; 9.90 wRVU, 90-day global)15121wRVU: 1.95 — STSG, face/scalp/neck/hands/feet/genitalia/etc., each additional 100 sq cm (true CPT add-on to 15120; 1.95 wRVU)
Skin defect / wound / burn requiring coverage
Same
Split-thickness skin graft harvest [right thigh / specify] and application to [wound location]
[Attending name], MD
[Resident/Fellow/PA name]
General / spinal / local with monitored sedation
Patient presents with [full-thickness wound / burn / skin defect] measuring [X x Y] cm on the [location]. [Wound bed prepared with granulation tissue]. [Prior debridement performed on X date.] Wound not suitable for primary closure or flap reconstruction. Split-thickness skin graft indicated for coverage. Donor site selected as [right / left anterolateral thigh]. Risks including graft failure, donor site complications, and need for regrafting discussed.
Recipient bed [X x Y] cm with [healthy granulation tissue / clean wound bed]. No active infection. Wound bed bleeding confirmed after debridement. Donor site [right thigh] healthy skin available.
The patient was positioned and both the recipient and donor sites prepped and draped in sterile fashion. [Recipient site debrided sharply to healthy bleeding tissue.]
The [right anterolateral thigh] donor site was infiltrated with tumescent solution [1:500,000 epinephrine in normal saline] to minimize bleeding and create a firm surface. Mineral oil applied to donor site.
A [0.012-inch / 0.015-inch] split-thickness skin graft was harvested from the [right thigh] using a powered [Zimmer / Humeca] dermatome, measuring approximately [X x Y] cm. The graft was meshed at a [1:1.5 / 1:3] ratio to expand coverage and allow drainage. The donor site was covered with [Xeroform / Mepitel One] dressing.
The meshed graft was applied to the recipient site, dermis-side down, with staples [or sutures] at the periphery and bolstered with a tie-over [or VAC] dressing to prevent shear. [Fibrin glue applied at edges.]
The patient tolerated the procedure well.
None
None
Minimal
[VAC dressing applied over graft / Tie-over bolster dressing]
Patient taken to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Skin defect / wound / burn requiring coverage, [location], *** cm²
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Split-thickness skin graft harvest, [right anterolateral thigh], and application to [wound location]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal / local with monitored sedation
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a [full-thickness wound / burn / skin defect] measuring *** × *** cm (*** cm²) on the [location]. Wound bed prepared with healthy granulation tissue. [Prior debridement performed ***]. Not suitable for primary closure. STSG indicated for coverage. Donor site: right anterolateral thigh. Risks including graft failure, donor site complications, and need for regrafting were discussed. Informed consent obtained.
FINDINGS: Recipient bed *** × *** cm with healthy granulation tissue, no active infection, adequate vascularity. Wound bed bleeding confirmed after sharp debridement. Right thigh donor site available.
DESCRIPTION OF PROCEDURE:
Patient positioned with both recipient and donor sites prepped in sterile fashion. Recipient site debrided sharply to healthy bleeding tissue. Right anterolateral thigh donor site infiltrated with tumescent solution (1:500,000 epinephrine in normal saline); mineral oil applied. A [0.012 / 0.015]-inch STSG harvested from the right thigh with powered [Zimmer / Humeca] dermatome, measuring *** × *** cm. Graft meshed at [1:1.5 / 1:3] ratio to expand coverage and allow drainage. Donor site covered with [Xeroform / Mepitel One] dressing. Meshed graft applied to recipient site dermis-side down, secured with staples at periphery. [Tie-over bolster / VAC dressing at 125 mmHg] applied over graft to prevent shear. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [VAC dressing over graft / Tie-over bolster dressing]
DISPOSITION: Patient taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Full-thickness skin graft (FTSG)
Anatomic site determines the code: CPT 15200 (FTSG, trunk, 20 sq cm or less, 8.92 wRVU) for trunk donor/recipient; CPT 15260 (FTSG, nose/ears/eyelids/lips, 20 sq cm or less, 11.35 wRVU) + 15261 add-on for facial defects. Do NOT use 15200 for facial FTSG — 15200 is a trunk code. Common donor sites: groin or supraclavicular (trunk-based, 15200); post-auricular or preauricular (facial-based, 15260). Document donor site and primary closure of donor defect.
Skin graft to burn wound
Document burn depth, total TBSA grafted, and number of graft sites. Burns use the same autograft codes as other wounds: 15100/15101 for trunk/extremities, 15120/15121 for face/hands/feet/genitalia. There is no separate burn-specific autograft CPT code family. For infant/child patients, the 15100/15120 descriptors include an alternative threshold of 1% of total body surface area — document patient weight and BSA when applicable.
VAC-assisted graft
Apply VAC at 75-125 mmHg over meshed graft for bolster. Document settings and planned POD 4-5 first dressing change.
Charting Tips
- Document graft thickness (thousandths of inch) and mesh ratio
- State recipient bed quality (granulation tissue, no infection, adequate vascularity confirmed by bleeding)
- Measure graft size applied vs. harvested and document overage
- Donor site dressing type and instructions for outpatient management
- CPT coding is based on total surface area of graft applied. Measure and document in cm².
- For 15120/15121: document the specific anatomic site (hand, foot, digit, genitalia, neck) that places the graft in the higher-reimbursed series rather than 15100
Billing Tips
- 15100 (STSG trunk/arm/leg first 100 sq cm, 9.65 wRVU, 90-day global) + 15101 add-on per each additional 100 sq cm (1.68 wRVU). Measure and document the exact graft area applied in sq cm.
- Anatomic region determines the code: 15100/15101 for trunk/extremities. For face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits — use 15120 (first 100 sq cm, 9.90 wRVU) + 15121 add-on per each additional 100 sq cm (1.95 wRVU). Note: 15120/15121 covers a broader anatomic set than just 'face' — hands, feet, genitalia, and multiple digits all fall under 15120, not 15100.
- Epidermal graft codes (15110, 15115) apply only when dermis is not included in the harvest (shave-thickness graft) and are distinct from STSG codes. STSG is the standard for most burns and wound beds.
- Donor site care is bundled. Do not separately bill dressing or wound care at the harvest site within the global period.
- Global period is 90 days (major). Any graft take evaluation or minor revisions within 90 days are bundled. For a planned staged return (e.g., scheduled regrafting of a partial take), use modifier -58. For an unplanned return to the OR due to graft failure, use modifier -78 (return to OR for related complication during global period). Modifier -58 is for planned staged procedures only — misapplying it to an unplanned failure will be denied.
- Meshing the graft does not change the CPT code. Document the mesh ratio (1:1.5, 1:3) in the operative note for clinical record.
- Debridement performed at the same session as skin grafting is bundled per CMS NCCI policy and cannot be separately billed — modifier -59 does NOT override this bundle. CPT codes 97597, 97598, 11042-11047, and 11000 are all bundled into 15100-15121 when performed on the same wound at the same encounter. Surgical preparation of the recipient site (CPT 15002-15005) may be separately reportable when performed on a different date prior to grafting.
General coding reference. Verify with your institution’s billing department before submitting claims.