Appropriate use of skin substitutes in dermatology: Documentation and coding guidance

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Senior Manager, Coding and Reimbursement, August 1, 2025

Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.

Skin substitutes are a diverse group of biologic, synthetic, or biosynthetic materials designed to provide temporary or permanent coverage of open skin wounds. In dermatology, they have become valuable adjuncts in the management of both acute and chronic wounds. Skin substitutes are particularly useful for covering defects in complex wounds or during reconstruction, especially when conventional wound care has failed to promote healing. These products, whether biologically active or synthetic, can facilitate re-epithelialization, modulate inflammation, and support tissue regeneration.

Therefore, their appropriate use, including careful selection, thorough documentation, and accurate coding, is essential to ensure both clinical effectiveness and proper reimbursement.

Types of skin substitutes include:

Naturally derived skin substitutes:

• Allografts - Human cadaver skin, provides temporary wound coverage and stimulates healing.

• Xenografts - Porcine skin offers a temporary protective barrier.

• Human amniotic membrane - A natural membrane used as a skin substitute providing anti-inflammatory and antimicrobial properties.

• Acellular dermal matrix - Processed dermal tissue, often derived from human or animal sources, to provide a scaffold for new tissue growth.

Tissue-engineered skin substitutes:

• Transcyte - Cellular allogeneic skin substitute made with a nylon mesh and a silicone layer containing allogenic fibroblasts, promoting wound healing.

• Apligraf - Composite skin graft with both living dermis and epidermis, used for treating chronic wounds.

• Dermagraft - Similar to Transcyte but lacks a silicone layer and contains viable fibroblasts.

Synthetic skin substitutes:

• Integra - Bilayered synthetic substitute with a collagen layer and a silicone layer, used for treating various wounds.

• Biobrane - Biosynthetic skin substitute composed of nylon mesh, silicone, and collagen, used as a temporary wound cover.

Each skin substitute offers a distinct set of advantages and limitations, making their use and subsequent reimbursement highly individualized. Because wound healing varies significantly from patient to patient, the selection of a skin substitute must be tailored to the specific clinical context. Key considerations include:

• The nature of the wound (e.g., acute vs. chronic)

• Its underlying cause (e.g., trauma, chronic inflammation, or surgery); and

• The skin layer involved — whether epidermal, dermal, or full-thickness.

Additionally, the intended functional and cosmetic outcomes play an important role in product selection, e.g., whether the substitute is intended to provide temporary coverage or serve as a permanent solution.

Before applying a specific skin substitute, dermatologists must be thoroughly familiar with payer coverage policies and documentation requirements. Medicare and private payers generally require documented evidence that the wound has not improved despite standard wound care for at least 4 weeks. Accurate coding and billing for skin substitutes require the use of both CPT and HCPCS codes to report the application procedure and the product used.

CPT^® codes 15271–15278 and C5271–C5278 are used to report the application of skin substitute grafts, with coding based on the anatomical site and total wound surface area. In parallel, HCPCS codes A2001–A2025, C9358–C9364, and Q4103–Q4310 identify the specific skin substitute product supplied.

Medicare Part B covers skin substitutes when they are used to treat chronic wounds on the lower extremity and/or to treat diabetic ulcers that have failed to heal with standard methods. Comprehensive documentation is essential for reimbursement and should include the product name, size, total area treated, and quantity used. Clear justification for medical necessity, along with proper coding, supports compliance and minimizes the risk of claim denials.

Documentation requirements for skin substitute use

Medicare requires that all documentation included in the patient’s medical record be made available upon request. Each page must include patient identifiers (e.g., full name, date of service) and the clinician’s legible signature. The medical record must support the selected ICD-10-CM diagnosis and CPT/HCPCS procedure codes and reflect that the local coverage document (LCD) criteria have been met.

It is important to note that Medicare provides limited coverage for use of skin substitutes which typically include wound and ulcer care, wound application of cellular and/or tissue-based products (CTPs), lower extremities as well as skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers.

Medicare further states that key documentation components should include:

• Clinical justification: A detailed explanation of why the ulcer has not healed with more than 4 weeks of standard care, including prior interventions and their outcomes.

• Ulcer description: A baseline and ongoing documentation of ulcer size, location, stage, duration, infection status, and response to treatment — updated at least every 4 weeks.

• Treatment plan: A description of the planned skin substitute therapy, including rationale for product choice, estimated duration, expected number of applications, and contingency plan if healing is not achieved.

• Risk and comorbidity management: Documentation that modifiable factors (e.g., diabetes control) and related conditions (e.g., venous disease) are being addressed.

• Procedure note: Includes the reason for graft application, full description of the procedure, product used (with packaging label), and operative findings. The first application starts the 12-to-16-week episode of care.

• Graphic or photographic evidence: Ulcer photos or measurements documenting wound characteristics at baseline and follow-ups.

• Wastage: If product wastage occurs, include date/time and location of ulcer(s) treated, product name of skin substitute grafts/cellular and/or tissue-based products (CTP) and package size, approximate amount of product used/discarded and manufacturer’s identification, reason for wastage (including the reason for using a package size larger than was necessary for the size of the ulcer, if applicable), and manufacturer’s serial/lot/batch number or other unit identification number of grafts/CTP material.
  
  If the manufacturer does not supply unit identification, the record must document that the information was not supplied. The amount billed as wastage must not exceed the product’s value.

  • Billing must align with clinical documentation in terms of wound size, location, and product units used.

Coding skin substitute services

Skin substitutes are an important component of dermatologic wound care, but their use must be medically necessary, thoroughly documented, and accurately coded. To ensure compliance and support optimal patient outcomes, dermatologists should stay current with coding updates and check payer coverage policies before rendering the service.

According to the AMA CPT definition, skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth. Skin substitute graft application codes are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.

CPT further states that non-graft wound dressings or injected skin substitute HCPCS codes should not be reported with skin substitute grafts/cellular and/or tissue-based products and HCPCS application codes, as this would be considered incorrect coding. Such products are bundled into other standard management procedures if medically necessary and are not separately payable. Do not report 15271–15278 or C5271–C5278 when a skin substitute is used for anything other than skin replacement surgery.

Select the appropriate code from 15271–15278 based on the anatomical location and total size of the defect. When treating multiple wounds, sum the surface areas of all wounds that fall within the same anatomical grouping as defined by the code descriptors. For example, combine the surface areas of wounds located on the trunk and arms, as they are part of the same grouping. Do not combine wounds from different anatomical groupings (e.g., do not sum surface areas for wounds on the face and arms).

Report the supply of skin substitute graft(s) separately when billing codes 15271–15278. For biologic implants used for soft tissue reinforcement, report 15777 in addition to the code for the primary procedure.

“Check payer coverage and payment policies before reporting skin substitutes. Medicare and private payers have specific coverage and payment limitations indicated in their LCD and coverage bulletins.”

Removal of a current graft and/or simple cleansing of the wound and other surgical preparation services are included in the skin substitute grafts/CTP and HCPCS application codes.

An evaluation and management (E/M) service should only be reported with a skin replacement therapy (application of skin substitute grafts/CTP) if the patient required a service that was separate and distinct from the skin replacement service.

Skin substitute application codes

Skin substitute graft/CTP codes below are for Diabetic Foot Ulcers (DFU) ONLY and must bereported on the same claim as a CPT/HCPCS application code



Skin substitute graft/CTP codes below are for Diabetic Foot Ulcer (DFU) or VenousLeg Ulcers (VLU) and must be reported on the same claim as a CPT/HCPCS application code

The following CPT/HCPCS codes are not-covered:

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