Summary & Overview
HCPCS Level II C5275: Low Cost Skin Substitute Graft, First 25 sq cm
HCPCS Level II code C5275 represents the application of a low cost skin substitute graft to complex and delicate anatomical areas — including the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and multiple digits — for a total wound surface area up to 100 sq cm, specifically covering the first 25 sq cm or less. This code is significant nationally as skin substitute grafting is increasingly used in wound care to promote healing in cosmetically and functionally important sites. Accurate coding of these procedures affects coverage determination, claims processing, and cost tracking across payers.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context for use of low cost skin substitutes in sensitive anatomical locations, the typical sites of service where applications occur, and what to expect from payer coverage patterns nationally. The publication provides benchmarks and policy-related considerations relevant to billing and coding teams, clinical administrators, and revenue cycle staff. Data not available in the input for specific payer policies, ICD-10 pairings, or related codes is noted where applicable.
Billing Code Overview
HCPCS Level II code C5275 describes the application of a low cost skin substitute graft to anatomical sites including the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits. The code applies when the total wound surface area is up to 100 sq cm, and specifically covers the first 25 sq cm or less of wound surface area.
Service type: Skin substitute graft application (low cost)
Typical site of service: Outpatient surgical settings, office-based procedures, ambulatory surgical centers, and other sites where topical grafting procedures for wounds on the face, head/neck, genitalia, hands, feet, or multiple digits are performed.
Clinical & Coding Specifications
Clinical Context
A 62-year-old male with a large full-thickness facial burn from a house fire presents to the outpatient burn reconstruction clinic 10 days after initial debridement. He has exposed subcutaneous tissue over the left cheek and periorbital area with partial-thickness wounds across the forehead and nose, total wound surface area approximately 65 sq cm. The reconstructive team elects application of a low-cost skin substitute graft to cover the facial defects to promote re-epithelialization and reduce donor-site morbidity.
The clinical workflow includes: initial evaluation and wound measurement; surgical debridement under local or monitored anesthesia care as needed; preparation of the wound bed and hemostasis; application and fixation of the low-cost skin substitute to the face and periorbital area; appropriate dressing and instructions for wound care; scheduled follow-up visits for graft assessment, dressing changes, and possible revision procedures. Documentation includes wound surface area calculation, anatomic sites treated (face, periorbital, neck, etc.), type of skin substitute used, anesthesia and operative details, and postoperative care plan. Billing uses C5275 for the first 25 sq cm or less of wound surface area when a low-cost skin substitute is applied to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |