General Surgery Coding Alert

Understanding the different procedure types is key to successful claim payment.

The spleen, a large, soft lymphatic organ, is centrally located in the abdominal cavity, nestled between the diaphragm and the stomach. This positioning makes it particularly vulnerable to damage. 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 often find yourself confused about how to code splenectomy procedures correctly, take a look at these frequently asked questions below to be sure to always submit clean claims from your surgical practice.

Question 1: How Does the Type of Procedure Determine the Code Choice?

Answer: CPT^® frequently lists abdominal procedure codes based on the surgical approach, and spleen codes are no different. You will need to know if the procedure was open or laparoscopic to code it correctly.

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))

Laparoscopic: 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.

Question 2: Does the Code Choice Change if Only Part of the Spleen Is Removed?

Answer: That depends. If the splenectomy was conducted laparoscopically, the specifics won’t affect the coding. However, if it was an open procedure, you’ll need to pay attention to the case details to ascertain whether a partial or total splenectomy was performed, as the coding options will vary accordingly.

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

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.

Partial open removal: Use code 38101. However, if the surgeon carries out an open repair of a ruptured spleen (splenorrhaphy) and excises a spleen segment during the procedure, report 38115 without an additional 38101 code.

Terminology: 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 key difference between codes 38100 and +38102 lies in whether the total splenectomy is conducted as an independent procedure (38100) or in conjunction with another open abdominal operation as a supplementary procedure (+38102).

Take note: To use the add-on code +38102, the splenectomy must be medically required due to spleen disease and not just incidental to the main procedure. An incidental splenectomy performed concurrently with a related procedure should not be separately reported, despite the availability of the code.

Question 3: What Is the Significance of the Term ‘Separate Procedure’?

Answer: Separate procedure codes can be used when the service is executed independently or in relation to an unrelated procedure, like surgery conducted during a different session or at a different anatomical location.

For example, 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.

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 Policy Manual (NCCI), 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.

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.”

Be aware: If you meet the above criteria, you may bill a bundled splenectomy code with another abdominal procedure using modifier 59 (Distinct procedural service) or the appropriate X{ESPU} modifier for separate encounter, structure, or practitioner, or unusual non-overlapping service, respectively.

Coding Example Wrap-Up

A 17-year-old patient complains of abdominal pain in the left upper quadrant and exhibits blurred vision and nausea after being involved in a car accident. The surgeon carries out an exploratory laparotomy and identifies injuries to both the spleen and a segment of the small intestine. Noting extensive splenic tears, the surgeon proceeds to bluntly dissect the spleen and remove it, ligating gastric arteries and clamping the splenic pedicle to control bleeding. Seeing a crushed section of small intestine and extensive bleeding, the surgeon also resects the damaged section and anastomoses the segments before closing.

The correct code for the enterectomy is 44120 (Enterectomy, resection of small intestine; single resection and anastomosis).

The total splenectomy in this case is an open procedure, which leaves you with two codes to choose from: 38100 or +38102.

In this scenario, the splenectomy should be coded as +38102, given that the surgeon is conducting the spleen removal due to severe injuries within the same anatomical region, affecting both the spleen and a part of the small intestine.

The NCCI includes 38100 as a column 2 code for 44120. While a modifier can override the edit pair, it’s not suitable here due to the procedures occurring at the same anatomical location. The CPT^® code book provides an add-on code for such situations.

Laparotomy: Although the op note mentions that the surgeon performed an exploratory laparotomy, you should not report 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)) in this case as it is already included as part of the splenectomy and enterectomy.

NCCI bundles 49000 as a column 2 code with both 44120 and +38102, as confirmed by the edit pairs showing a modifier indicator of “0.” This indicates that the edit pair cannot be overridden under any conditions.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC