How To Use CPT Code 38102

CPT 38102 describes the excision procedure performed on the spleen in conjunction with another extensive procedure. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38102?

CPT 38102 can be used to describe the excision of the spleen as part of a larger resection of diseased tissue. This code is used when the provider performs a complete removal of the spleen while performing another extensive procedure that requires excision of abdominal organs. The most common reasons for performing this procedure are trauma or cancer of the abdominal organs.

2. Official Description

The official description of CPT code 38102 is: ‘Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary procedure)’. This code is an add-on code and should only be used to identify the removal of the spleen as part of a larger resection of diseased tissue.

3. Procedure

1. When performing CPT 38102, the provider begins by appropriately prepping and anesthetizing the patient.
2. An existing incision from another procedure is made or extended to access the area of disease.
3. The provider then determines the best approach to remove the diseased tissue, including the spleen.
4. The arteries and veins of the spleen are ligated and incised.
5. All ligaments supporting the spleen are incised to completely free it.
6. The spleen is then removed in its entirety.
7. After the procedure, the surgical site is irrigated and the wound is closed in layers with sutures.

4. Qualifying circumstances

CPT 38102 is performed on patients who require the excision of the spleen as part of a larger resection of diseased tissue. This procedure is commonly performed on patients with trauma or cancer of the abdominal organs. It is important to note that CPT 38102 should not be reported alone and should only be used in conjunction with the primary procedure code.

5. When to use CPT code 38102

CPT code 38102 should be used when the provider is performing a total splenectomy as part of a larger resection of diseased tissue. It should not be reported alone and should always be listed in addition to the code for the primary procedure. This code is specifically used for extensive disease cases where the removal of the spleen is necessary.

6. Documentation requirements

To support a claim for CPT 38102, the provider must document the following information:

• Reason for the procedure, such as trauma or cancer of the abdominal organs
• Details of the primary procedure and the need for splenectomy
• Date of the procedure
• Specific steps taken during the procedure, including the ligation and incision of arteries and veins, and the complete removal of the spleen
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 38102, ensure that the procedure is performed as part of a larger resection of diseased tissue. This code should not be reported alone and should always be listed in addition to the code for the primary procedure. It is important to follow the specific guidelines provided by the payer regarding the use of modifiers and the reporting of multiple surgeons or surgical assistants.

8. Historical information

CPT 38102 was added to the Current Procedural Terminology system on January 1, 1994. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs a total splenectomy as part of a Whipple procedure for a patient with pancreatic cancer.
2. A patient with trauma to the abdominal organs undergoes a total splenectomy along with the excision of other diseased tissue.
3. A provider performs a total splenectomy as part of a gastric bypass surgery for a patient with obesity and spleen-related complications.
4. A patient with extensive disease in the abdominal organs undergoes a total splenectomy along with the removal of the pancreas and duodenum.
5. A provider performs a total splenectomy as part of a liver resection procedure for a patient with liver cancer.
6. A patient with trauma to the abdominal organs undergoes a total splenectomy along with the removal of the stomach and colon.
7. A provider performs a total splenectomy as part of a Whipple procedure for a patient with ampullary cancer.
8. A patient with extensive disease in the abdominal organs undergoes a total splenectomy along with the removal of the small intestine and gallbladder.
9. A provider performs a total splenectomy as part of a gastric sleeve surgery for a patient with obesity and spleen-related complications.
10. A patient with trauma to the abdominal organs undergoes a total splenectomy along with the removal of the liver and kidney.