Split-Thickness Skin Graft (STSG)

CPT 15100
Approach Open
Add-on / Variant CPTs
  • 15101 — STSG, each additional 100 sq cm
  • 15120 — STSG, face, scalp, eyelids, nose, ears (first 100 sq cm)
  • 15271 — Application of skin substitute graft
Preoperative Diagnosis:

Skin defect / wound / burn requiring coverage

Postoperative Diagnosis:

Same

Procedure Performed:

Split-thickness skin graft harvest [right thigh / specify] and application to [wound location]

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General / spinal / local with monitored sedation
Patient supine [or as dictated by wound location].

Indications:

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.

Findings:

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.

Description of Procedure:

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.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

[VAC dressing applied over graft / Tie-over bolster dressing]

Disposition:

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
.TODAY
Variants

Full-thickness skin graft (FTSG)

CPT 15200. For facial defects. Document donor site (groin, post-auricular), harvest technique, and primary donor closure.

Skin graft to burn wound

Document burn depth, total TBSA grafted, and number of grafts. Burn-specific CPT codes apply.

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)
  • 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. Measure and document in cm².
Billing Tips
  • 15100 (STSG trunk/arm/leg first 100 sq cm, 9.65 wRVU) + 15101 add-on per additional 100 sq cm (1.68 wRVU). Measure and document the exact graft area in sq cm.
  • Anatomic region drives code: 15100/15101 for trunk/extremities, 15120/15121 for face/scalp/neck/hands/feet/genitalia (slightly higher wRVU).
  • Epidermal graft codes (15110, 15115) 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 (major). Any graft take evaluation or minor revisions within 90 days are bundled. Failed graft requiring repeat procedure uses modifier -58 (staged).
  • 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.
  • If wound bed preparation (debridement) was performed at the same session, it may be separately billable with modifier -59. Document separately performed debridement (97597/97598) vs. integrated preparation.