CPT 15116: Epidermal Autograft, Additional Area for Complex Regions - OpenPayer

Beta

OpenPayer Beta

Summary & Overview

CPT 15116: Epidermal Autograft, Additional Area for Complex Regions

CPT code 15116 represents an add-on procedure for epidermal autograft surgeries, targeting sensitive and complex anatomical regions such as the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. This code is used when additional grafting is required beyond the initial area covered by the primary procedure, making it essential for comprehensive skin replacement treatments, especially in cases involving extensive wounds or ulcers.

Nationally, this code is recognized by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Its inclusion in payer policies highlights the importance of accurate billing and documentation for advanced skin graft procedures. Readers will gain insights into payer coverage, clinical indications, and the typical outpatient hospital setting where these procedures are performed. The publication also addresses relevant modifiers, associated taxonomies, and ICD-10 diagnoses commonly linked to this code, providing a thorough overview of its clinical and billing context.

Key benchmarks and policy updates are discussed to inform stakeholders about current trends in reimbursement and utilization. The summary offers a clear understanding of how CPT code 15116 fits into the broader landscape of skin replacement surgery, supporting informed decision-making for healthcare professionals, administrators, and policy analysts.

AetnaBlue Cross Blue ShieldCigna HealthMedicareUnitedHealthcareCPT 15116epidermal autograftskin replacement surgeryoutpatient hospitaladd-on procedurecomplex anatomical regionsmedical billingclinical benchmarkspolicy updatesICD-10 diagnoses

CPT Code Overview

CPT code 15116 is used to report an epidermal autograft procedure for areas such as the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits. This code specifically covers each additional 100 square centimeters, or each additional one percent of body area for infants and children, performed as an add-on to the primary procedure. The typical site of service for this procedure is an outpatient hospital setting, reflecting its use in advanced skin replacement surgeries where precise grafting is required for complex anatomical regions.

Clinical & Coding Specifications

Clinical Context

A patient presents to the outpatient hospital with a chronic, non-healing wound on the lower leg, such as a non-pressure chronic ulcer or an open wound following trauma or surgery. The wound has not responded to conservative management and requires surgical intervention. The provider performs an epidermal autograft procedure to cover the affected area, starting with the first 100 sq cm (or one percent of body area for infants and children) using CPT code 15115. If the wound area exceeds this initial measurement, CPT code 15116 is used for each additional 100 sq cm or each additional one percent of body area. The procedure is typically performed by a surgery physician, plastic surgery physician, or family medicine physician, depending on the clinical scenario and patient needs.

Coding Specifications

Modifiers:
- Modifier 59: Distinct Procedural Service. Used when the epidermal autograft procedure is performed separately from other procedures on the same day, indicating a distinct service.
- Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. Used when the same provider repeats the epidermal autograft procedure during the same encounter or on a different date.
Provider Taxonomies:

National Reimbursement Benchmarks

Medicare's national mean rate for CPT code 15116 is $167.19, which is notably lower than the BUCA (average commercial) mean rate of $214.01. Commercial payers such as UnitedHealth Group and Cigna report even higher mean rates, at $271.05 and $249.51 respectively, while Blue Cross Blue Shield and Aetna are closer to the BUCA average.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range at $13.00, indicating relatively consistent reimbursement. In contrast, UnitedHealth Group shows the widest dispersion at $161.04, followed by Cigna at $140.36, reflecting greater variability in commercial rates. Blue Cross Blue Shield and BUCA also display moderate ranges, while Aetna's dispersion is comparatively narrow among commercial payers.

The table and chart below present a detailed breakdown of national mean rates and percentile values for each payer.

State Benchmarks

State: AK1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 15116 are notably higher than national averages across all major payers. The mean rates for commercial payers such as Aetna, Blue Cross Blue Shield, Cigna, UnitedHealth Group, and BUCA are substantially above their respective national benchmarks, with Aetna leading at $654.39. Medicare's mean rate in Alaska, while lower than commercial payers, is still close to the national Medicare average. The rate spread, calculated as the difference between the 75th and 25th percentiles, varies by payer. Aetna's rates are consistent across all percentiles, indicating little variation, while Cigna shows a wider spread from $194.88 to $421.50, suggesting more variability in reimbursement.

The table and chart below present the full breakdown of payer-specific rates in Alaska, highlighting the differences in mean, median, and percentile values. This detailed view allows for a clear comparison of how each payer reimburses for CPT code 15116 within the state.

Key Insights for Alaska

Aetna is the highest paying payer for CPT 15116 in Alaska, with a mean rate of $654.39, while Medicare is the lowest at $164.11.
All commercial payers in Alaska reimburse significantly above their respective national averages for this code.
The rate spread is widest for Aetna, with all percentiles at $718.50, indicating a consistent high payment, while Cigna shows the lowest 25th percentile at $194.88.

Related Codes

16035

CPT 16035: Escharotomy, Initial Incision for Severe Burn Treatment

16027

CPT 16027: Escharotomy, Each Additional Incision

15108

CPT 15108: Split-Thickness Autograft, Face/Head ≤100 sq cm

15120

CPT 15120: Split-Thickness Autograft for Sensitive Areas, First 100 sq cm

15121

CPT 15121: Split-Thickness Autograft for Sensitive Anatomical Areas

15107

CPT 15107: Skin Substitute Graft Application to Trunk/Extremities

15111

CPT 15111: Epidermal Autograft for Trunk, Arms, or Legs

15114

CPT 15114: Split-Thickness Autograft Application, Additional 100 sq cm

16036

CPT 16036: Escharotomy, each additional incision

15117

CPT 15117: Skin Substitute Graft Application to Trunk, Arms, or Legs

Showing 1–10 of 42

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Free Report

See how your rates compare to the market.

Get a free custom competitive market analysis.