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Official Description

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, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 15002 refers to the surgical preparation or creation of a recipient site through the excision of open wounds, burn eschar, or scars, which may include the underlying subcutaneous tissues. This procedure is particularly relevant for the trunk, arms, and legs of infants and children. The process involves the physician excising damaged or unhealthy tissue to prepare a suitable area for skin grafting. This may also include the incisional release of scar contractures, which are tight areas of skin that can restrict movement and cause discomfort. The goal of this procedure is to create a healthy bed of vascular tissue that can support a skin graft, thereby facilitating the repair of the defect. The code specifically covers the first 100 square centimeters or 1% of the body area in infants and children, making it essential for accurate reporting in pediatric cases. For larger areas, additional codes, such as CPT® Code 15003, are used to report each subsequent 100 square centimeters or 1% of body area, ensuring comprehensive documentation and billing for the surgical services provided.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure represented by CPT® Code 15002 is indicated for various conditions that necessitate the surgical preparation of a recipient site for skin grafting. These indications include:

  • Open Wounds - These are injuries that have not healed properly and require surgical intervention to prepare the site for grafting.
  • Burn Eschar - This refers to the dead tissue that forms over a burn injury, which must be excised to allow for proper healing and grafting.
  • Scars - Existing scars that may be causing functional impairment or cosmetic concerns can be excised or released to facilitate grafting.
  • Scar Contractures - These are tight areas of skin resulting from scarring that restrict movement and may require incisional release to improve function and prepare the site for grafting.

2. Procedure

The procedure for CPT® Code 15002 involves several critical steps to ensure the recipient site is adequately prepared for skin grafting. The steps include:

  • Excision of Open Wounds - The physician begins by carefully excising any open wounds present on the trunk, arms, or legs. This step is crucial to remove any necrotic or infected tissue that could impede healing.
  • Removal of Burn Eschar - If burn eschar is present, it is excised to expose healthy tissue beneath. This is essential for creating a viable surface for the skin graft.
  • Scar Excision or Incisional Release - The physician may also excise existing scars or perform an incisional release of scar contractures. This step helps to alleviate tension in the skin and allows for better integration of the graft.
  • Debridement and Granulation Tissue Removal - Simple debridement may be performed to remove any remaining unhealthy tissue or granulation tissue, ensuring that the recipient site is clean and well-vascularized.
  • Preparation of the Recipient Site - After the excision and debridement, the physician prepares the recipient site to ensure it has a healthy bed of vascular tissue, which is critical for the success of the subsequent skin graft.

3. Post-Procedure

Post-procedure care following the surgical preparation for skin grafting is essential for optimal healing and recovery. Patients may require monitoring for signs of infection at the excision site. Additionally, proper wound care instructions will be provided to ensure the area remains clean and protected. The physician may also schedule follow-up appointments to assess the healing process and determine the appropriate timing for the placement of the skin graft. Pain management may be necessary, and the healthcare team will provide guidance on activity restrictions to promote healing and prevent complications.

Short Descr WOUND PREP TRK/ARM/LEG
Medium Descr PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT
Long Descr 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, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 172 - Skin graft

This is a primary code that can be used with these additional add-on codes.

15003 Addon Code MPFS Status: Active Code APC N ASC N1 Illustration for Code 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, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
GC This service has been performed in part by a resident under the direction of a teaching physician
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
RT Right side (used to identify procedures performed on the right side of the body)
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GW Service not related to the hospice patient's terminal condition
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
LT Left side (used to identify procedures performed on the left side of the body)
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
A2 Dressing for two wounds
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
E1 Upper left, eyelid
ET Emergency services
F1 Left hand, second digit
F2 Left hand, third digit
GA Waiver of liability statement issued as required by payer policy, individual case
GJ "opt out" physician or practitioner emergency or urgent service
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GZ Item or service expected to be denied as not reasonable and necessary
KX Requirements specified in the medical policy have been met
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
T1 Left foot, second digit
T5 Right foot, great toe
T7 Right foot, third digit
TA Left foot, great toe
U1 Medicaid level of care 1, as defined by each state
U7 Medicaid level of care 7, as defined by each state
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
Date
Action
Notes
2011-01-01 Changed Short description changed. Guideline information changed.
2007-01-01 Added New code
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