Summary & Overview
CPT 15131: Dermal Autograft, Trunk/Arms/Legs (Additional Area)
CPT code 15131 designates an additional-area dermal autograft for the trunk, arms, or legs — billed per extra 100 cm2 in adults or per additional 1% body surface area in pediatric patients. This add-on surgical code is appended alongside the primary grafting procedure when clinicians harvest and place extra dermal graft material to achieve adequate wound coverage. Nationally, accurate use of this code affects surgical billing clarity, reimbursement accuracy, and aggregate utilization measurement for reconstructive and burn-related care.
Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise briefing on the clinical context for dermal autografting, the typical sites of service, and how CPT code 15131 functions as an adjunct to primary graft codes. The publication also outlines common modifiers used with this service, payer coverage considerations, and benchmarking topics relevant to hospitals and ambulatory surgery centers.
This summary equips coding, revenue cycle, and clinical teams with the operational context needed to recognize when CPT code 15131 applies, what aspects of care it represents, and which payers are typically involved. Data not available in the input on associated taxonomies, specific ICD-10 pairings, and payer-specific edits are identified elsewhere in the full publication.
Billing Code Overview
CPT code 15131 describes a dermal autograft procedure for the trunk, arms, or legs. The code is used for the additional grafted area and specifies coverage for each additional 100 cm2 in an adult or each additional 1 percent of body surface area in an infant or child. This code is reported separately in addition to the code for the primary procedure.
Service Type: Dermal autograft (additional graft area)
Typical Site of Service: Operating room or surgical suite in an inpatient or outpatient hospital setting, ambulatory surgery center, or specialty surgical clinic
Clinical & Coding Specifications
Clinical Context
A 45-year-old male presents to a burn center after sustaining a deep partial- to full-thickness thermal burn to his left thigh and anterior trunk following a residential fire. After initial resuscitation and debridement, wound beds are prepared and a split-thickness skin graft is applied for the primary coverage. Due to areas requiring thicker dermal replacement to improve contour and durability over joints, a dermal autograft procedure is performed to augment the reconstruction of the trunk and leg. The operative report documents the primary procedure and additional dermal autograft harvests measuring an extra 300 cm2; 15131 is reported in addition to the primary grafting code to account for each additional 100 cm2 of dermal autograft in an adult.
The clinical workflow includes preoperative evaluation (consent, anesthesia assessment), operative measurement and harvesting of autologous dermal tissue, placement and fixation of the dermal grafts, hemostasis, dressing application, and postoperative monitoring in the ambulatory surgical or inpatient burn unit. Documentation must include exact graft surface area, donor sites, indication, concurrent primary graft code, and any complications or staged procedures.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work or time substantially exceeds the usual for 15131, with documentation of additional work. |
23 | Unusual anesthesia | Use when medically necessary anesthesia is provided for a procedure that is usually performed with local anesthesia for 15131. |
26 | Professional component | Use if reporting only the professional component when services are split (rare for surgical grafting). |
50 | Bilateral procedure | Use when the additional dermal autograft is performed bilaterally and payer requires bilateral reporting for 15131. |
52 | Reduced services | Use when the dermal autograft procedure is partially reduced or not completed as originally planned. |
53 | Discontinued procedure | Use when the dermal autograft is started but discontinued for documented clinical reasons. |
59* | Distinct procedural service | Not listed in provided modifiers; not included. |
62 | Two surgeons | Use when two surgeons work together as primary surgeons performing the dermal autograft. |
63 | Procedure performed on infants less than 4 kg | Use when 15131 is performed on an infant meeting the weight criteria. |
66 | Surgical team | Use when a surgical team is required for complex multilayer grafting involving 15131. |
78 | Return to OR for related procedure during postoperative period | Use if patient returns to operating room for revision or management related to the dermal autograft. |
79 | Unrelated procedure during postoperative period | Not listed in provided modifiers; not included. |
80 | Assistant surgeon | Use when an assistant surgeon performs supportive surgical tasks during the dermal autograft. |
81 | Minimum assistant surgeon | Use when a minimal assistant role is documented for the dermal autograft. |
82 | Assistant surgeon (when qualified resident not available) | Use when no qualified resident is available and an assistant surgeon is required. |
AS | Physician assistant, nurse practitioner, or clinical nurse specialist services | Use to identify services by these non-physician practitioners supporting the procedure when allowed. |
ET | Registered nurse first assistant | Use when a registered nurse first assistant provides documented intraoperative assistance for 15131. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207L00000X | Dermatology | Dermatologic surgeons perform grafting for complex skin defects and burns. |
208600000X | Plastic Surgery | Plastic surgeons frequently perform dermal autograft procedures for reconstruction. |
208800000X | General Surgery | General surgeons with burn or trauma expertise may perform trunk and limb grafting. |
290000000X | Burn Surgery (Surgical Critical Care/Burn Specialist) | Specialists in burn care manage complex autograft procedures and postoperative care. |
363L00000X | Wound Care (Physician) | Wound care specialists coordinate pre- and postoperative management of grafts. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
T31.2 | Burns of multiple body regions, 10-19% of body surface | Indicates burn extent where dermal autograft may be required for trunk/limb reconstruction. |
T31.3 | Burns of multiple body regions, 20-29% of body surface | Larger BSA burns often require staged grafting including dermal autografts. |
T22.209A | Burn of unspecified degree of left thigh, initial encounter | Site-specific burn diagnosis necessitating grafting procedures like 15131. |
T21.2XXA | Burn and corrosion of second degree of trunk, initial encounter | Partial-thickness burns of trunk that can require dermal autograft augmentation. |
L98.4 | Non-healing surgical wound | Chronic wound states that may need dermal autograft for durable coverage. |
S71.011A | Unspecified open wound of right thigh, initial encounter | Traumatic wounds on limbs that may require autograft reconstruction including dermal components. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
15100 | Split-thickness skin graft, trunk, arms, legs; first 100 sq cm or less, or; each additional 100 sq cm, or each additional 1 percent BSA of autograft for infants/children | Often used as the primary grafting code performed alongside a dermal autograft; 15131 is reported in addition to primary graft codes for extra dermal autograft area. |
15240 | Full-thickness skin graft, head and neck; first 100 sq cm or less | May be used for nearby donor or recipient sites when full-thickness grafting is required in conjunction with dermal autograft procedures. |
15730 | Dermabrasion; trunk, arms, legs, or hands, first 100 sq cm | Performed occasionally to prepare scarred or irregular recipient beds prior to dermal autografting. |
16020 | Local excision of granulation tissue; complicated | Used when debridement or excision of nonviable tissue is required before dermal autograft placement. |
13160 | Secondary closure of surgical wound or scar revision, extensive | May be performed in staged reconstruction when dermal autograft integration requires revision. |