How To Use CPT Code 38100

CPT 38100 describes the total splenectomy procedure, which involves the complete excision of the spleen. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38100?

CPT 38100 is used to describe the total splenectomy procedure, which involves the complete removal of the spleen. This code is used when the provider makes an incision into the abdominal cavity and performs a complete excision of the spleen. The procedure is typically performed for patients with a traumatic rupture of the spleen, hemolytic anemia, or cancer of the spleen.

2. Official Description

The official description of CPT code 38100 is: ‘Splenectomy; total (separate procedure).’ This code represents the complete removal of the spleen as a separate procedure.

3. Procedure

1. The provider begins by making an incision into the abdominal cavity, typically just below the left ribs.
2. They then expose the spleen and release it from the surrounding structures.
3. The provider ligates the arteries and veins of the spleen and divides them.
4. All ligaments supporting the spleen are incised to completely free it.
5. The spleen is then removed in its entirety.
6. After the procedure is complete, the surgical site is irrigated and a drain may be placed.
7. The provider closes the wound in layers with sutures and applies a dressing.

4. Qualifying circumstances

CPT 38100 is performed for patients with specific conditions that require the complete removal of the spleen. These conditions include traumatic rupture of the spleen, hemolytic anemia, or cancer of the spleen. The procedure is typically performed by a qualified healthcare provider in a hospital or surgical setting.

5. When to use CPT code 38100

CPT code 38100 should be used when the provider performs a total splenectomy as a separate procedure. It should not be reported if the provider performs any other major procedure in the same location and session. For a laparoscopic approach, a different code, such as 38120, should be used.

6. Documentation requirements

To support a claim for CPT 38100, the provider must document the following information:

• Patient’s diagnosis necessitating the total splenectomy
• Details of the procedure, including the incision, removal of the spleen, and closure of the wound
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 38100, ensure that the procedure is performed as a separate procedure and not in conjunction with any other major procedure in the same location and session. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 38100 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, it is important to stay updated with any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A patient with a traumatic rupture of the spleen undergoes a total splenectomy to remove the damaged organ.
2. A patient with hemolytic anemia requires a total splenectomy to address the abnormal destruction of red blood cells.
3. A patient diagnosed with cancer of the spleen undergoes a total splenectomy as part of their treatment plan.
4. A provider performs a total splenectomy for a patient with a combination of hemolytic anemia and cancer of the spleen.
5. A patient with a traumatic rupture of the spleen and concurrent cancer of the spleen undergoes a total splenectomy to address both conditions.
6. A provider performs a total splenectomy for a patient with a traumatic rupture of the spleen and subsequent hemolytic anemia.
7. A patient with cancer of the spleen undergoes a total splenectomy as the primary treatment modality.
8. A provider performs a total splenectomy for a patient with cancer of the spleen and concurrent hemolytic anemia.
9. A patient with hemolytic anemia and concurrent cancer of the spleen undergoes a total splenectomy to address both conditions.
10. A provider performs a total splenectomy for a patient with a traumatic rupture of the spleen and subsequent cancer of the spleen.