Basics about Splenectomy CPT code

The spleen is soft and spongy, making it vulnerable to injury and other trauma. Unlike some organs, it can be removed, and other organs in the lymphatic system can take over many of the activities it performs. Hence, when the spleen fails to function properly due to trauma, leukemia and other cancers, infection, tumor, or some other disease that causes the spleen to enlarge beyond its normal size, a splenectomy (the surgical removal of the spleen) may be performed. CPT code 38100, 38101 & +38102 are used for splenectomy procedures.

A total splenectomy (CPT code 38100) is performed. An incision is made in the abdomen and the spleen exposed. The spleen is mobilized and displaced medially to expose the splenorenal, splenocolic, and gastrosplenic ligaments. If the spleen is significantly enlarged or if it has ruptured, the splenic artery is located first and ligated to reduce the size of the spleen or prevent further hemorrhage. Otherwise, the splenorenal, splenocolic, and gastrosplenic ligaments are ligated, and divided prior to tying off the splenic artery.

The splenic artery and vein are then visualized, ligated and divided. The spleen is removed and the surgery site inspected for bleeding with particular attention being paid to the splenic pedicle and retroperitoneal space. Any bleeding is controlled by electrocautery or by suture ligation of blood vessels. The wound is irrigated and the abdomen closed. In CPT code 38101, a partial splenectomy is performed. The diseased or damaged portion of the spleen is visualized. Following mobilization of the spleen, the spleen is incised and the diseased or damaged portion excised. The remaining spleen segment is repaired by sutures or staples.

The splenic artery may be ligated if bleeding is not controlled by sutures and staples alone. The remaining spleen segment may be wrapped in omentum or synthetic mesh. A drain may be inserted. The abdomen is then closed around the drain. In CPT code 38102, an en bloc total splenectomy is performed for extensive disease in conjunction with another procedure. The en bloc total splenectomy is performed as described above.

Splenectomy: Removal of the spleen.

Splenoportography: Introduction of radiopaque material into the spleen to obtain radiographic visualization of the splenic and main portal veins of the portal circulation.

Splenorrhaphy: Suturing of a ruptured spleen.

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Description of splenectomy cpt code 38100, 38101 & +38102

The CPT codes in this subsection report a traditional, open splenectomy. An incision is made in the middle of the patient’s abdomen. Muscle and tissue are visualized, and the spleen is located and removed. Code selection is based on the extent of the removal.

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)

The physician makes a midline incision and dissects tissue around the spleen. The short stomach vessels are doubly ligated and cut. The splenic recess is dissected and the splenic artery and vein are divided and cut individually. The physician removes the spleen. A drain may be placed and the wound is irrigated. The incision is closed with sutures or staples and a dry dressing is applied. CPT code 38101 should be reported if performed a partial splenectomy; and CPT code 38102 is assigned if performed a total splenectomy in conjunction with another procedure.

Codes 38100 and 38101 are designated as separate procedures that may be reported when performed alone or with an unrelated procedure(s). Append modifier 59 when performed with other procedures/services.

CPT code 38100 is reported to identify the complete removal of the ruptured spleen. Code 49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure), which identifies the exploratory laparotomy, is not reported because a laparotomy is an integral part of a splenectomy and is not reported separately.

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RVU and Fees for CPT code 38100

RVU and Fees for CPT code 38101

RVU and Fees for CPT code 38102