Dermatology Coding Alert

You Be the Coder:

Full-Thickness Graft

Question: The dermatologist placed a full-thickness graft on a patient’s forehead, totaling 36 sq cm. What code or codes should I report? 

Idaho Subscriber

Answer: In this case, you select CPT® code 15240 (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) for the first 20 cm and +15241 (... each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]) for the remaining 16 sq cm. 

In order to report your skin graft procedures correctly, you must be sure that your dermatologist documents the size, location and depth of every graft. Otherwise, you run the risk of receiving reimbursement for a lower-paying split-thickness graft.