Split-Thickness Skin Graft (STSG)
Skin defect / wound / burn requiring coverage
Same
Split-thickness skin graft harvest [right thigh / specify] and application to [wound location]
[***, MD/DO]
[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)
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. There is no separate burn-specific autograft reporting options family.
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
- Code selection is based on total surface area of graft applied. Measure and document in cm².
- For grafts to the hand, foot, digit, genitalia, or neck, document the specific anatomic site, which places the graft in the higher-valued series
Documentation & Reimbursement Considerations
- Primary service: Report Split-Thickness Skin Graft (STSG) as the primary service when it is the definitive operation performed.
- Split-thickness skin graft to the trunk, arms, or legs is reported for the first 100 sq cm (9.65 wRVU, 90-day global) plus an add-on for each additional 100 sq cm (1.68 wRVU). Measure and document the exact graft area applied in sq cm.
- Anatomic region determines the code. Grafts to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, or multiple digits use a separate, higher-valued series (9.90 wRVU for the first 100 sq cm, 1.95 wRVU per additional 100 sq cm), not the trunk and extremity series.
- Epidermal graft codes apply only when dermis is not included in the harvest 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. Graft take evaluation and minor revisions within 90 days are bundled. A planned staged return (e.g., scheduled regrafting of a partial take) uses the staged-procedure modifier, and an unplanned return to the OR for graft failure uses the unplanned-return modifier. Applying the staged-procedure modifier to an unplanned failure will be denied.
- Meshing the graft does not change the code. Document the mesh ratio (1:1.5, 1:3) in the operative note for the clinical record.
- Debridement of the same wound at the same session is bundled into skin grafting per CMS NCCI policy, and a distinct-procedural-service modifier does not override this bundle. Surgical preparation of the recipient site may be separately reportable when performed on a different date before grafting.