General Surgery Coding Alert

Master ‘separate procedure’ rules to perfect your claims.

The spleen manages to get in the middle of many op reports with repair or partial/total removal, either alone or with other abdominal procedures.

Here’s why: The spleen is in the middle of things anatomically, and is very susceptible to injury — a large, soft, lymph organ on the left of the abdominal cavity between the diaphragm and the stomach. Because other lymph organs can replace the spleen’s function, surgeons may need to remove the organ if trauma, cancer, infection, or enlargement makes that a desirable option.

If you find yourself trying to untangle when and how to code your surgeon’s spleen services, help is here with the following three tips.

Tip 1: Distinguish Open or Laparoscopic Procedure

CPT^® frequently lists abdominal procedure codes in different subsections based on the surgical approach, and spleen codes are no different.

Open: If the surgeon performs an open splenectomy, you should turn to the following codes from the spleen “Excision” CPT^® subsection:

• 38100 (Splenectomy; total (separate procedure))
• 38101 (… partial (separate procedure))
• +38102 (… total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure))

Lap: If the op report describes a laparoscopic procedure, on the other hand, you have these two codes to choose from:

• 38120 (Laparoscopy, surgical, splenectomy)
• 38129 (Unlisted laparoscopy procedure, spleen)

Both: CPT^® provides just one code for spleen repair, typically through suturing — 38115 (Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy). You’ll find that code in the “Repair” CPT^® subsection, and you should use it to code your surgeon’s repair of a ruptured spleen whether it involves a laparoscopic or open approach.

Tip 2: Look for Partial or Total

Once you’ve determined if the surgeon performs an open or laparoscopic splenectomy, you have more choices to make based on case specifics.

Laparoscopic: CPT^® does not distinguish between a partial or total splenectomy with the laparoscopic codes. You’ll turn to the same code whether your surgeon removes all or part of the spleen laparoscopically: 38120.

On the other hand, “if the surgeon performs a different laparoscopic spleen procedure, such as removing a cyst, you should use 38129,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif.

Open: If the surgeon opens the abdomen for the procedure, you’ll need to check the op note to see if it involves total or partial spleen removal. For a total open splenectomy, you must choose between 38100 and +38102.

Vocabulary: Don’t be fooled by the term “en bloc” in the +38102 code definition. The term simply means to remove as a whole, so en bloc is synonymous with total.

“The real distinction between 38100 and +38102 is whether the surgeon performs the total splenectomy as a stand-alone procedure (38100) or together with another open abdominal surgery as an additional procedure (+38102),” Joy says.

Caution: To report add-on code +38102, the splenectomy must be medically necessary (for disease of the spleen) and not merely incidental to the primary procedure. Even though the code is available, you should not separately report an incidental splenectomy performed at the same time as another, related procedure.

Partial: If the surgeon performs an open partial splenectomy, use code 38101. “But if the surgeon performs an open repair of a ruptured spleen (splenorrhaphy) and removes a segment of the spleen as a part of that procedure, you should report 38115 and not additionally code 38101,” Joy says.

Tip 3: Understand ‘Separate Procedure’

You’ll notice that 38100 and 38101 include the parenthetic descriptor, (separate procedure). Contrary to what some coders think, that doesn’t mean you should reserve 38100 or 38101 for cases when it’s the only service the surgeon carries out at that session.

“You can report ‘separate procedure’ codes when the service is performed alone or with another procedure that is unrelated, such as a surgery at a different session or anatomic site,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

CPT^®: The Surgery Guidelines state, “Some of the procedures or services listed in the CPT^® code book that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term ‘separate procedure’ [and] should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.”

NCCI: The National Correct Coding Initiative (NCCI) Policy Manual, Chapter 1 Section C-6 states that a CPT^® separate-procedure code “is not separately reportable if performed in a region anatomically related to the other procedure(s) through the same skin incision, orifice, or surgical approach.”

That’s why you’ll find NCCI edit pairs for separate-procedure-splenectomy codes with many abdominal surgeries.

Opportunity: The Policy Manual goes on to state in Chapter 1 Section J that you may report a separate-procedure code with bundled code “if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area often through a separate skin incision, orifice, or surgical approach.”