How To Use CPT Code 38115

CPT 38115 describes the repair of a ruptured spleen, also known as splenorrhaphy, with or without partial splenectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 38115?

CPT 38115 can be used to describe the surgical repair of a ruptured spleen, also known as splenorrhaphy. This procedure involves making an incision into the abdominal cavity and repairing the damaged area of the spleen with sutures. In some cases, a portion of the spleen may need to be excised if it is irreparable. The most common reason for performing this procedure is trauma.

2. Official Description

The official description of CPT code 38115 is: ‘Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy.’

3. Procedure

1. The provider begins by making an incision into the abdominal cavity, typically below the left ribs.
2. Once the spleen is exposed, the provider assesses the area of damage.
3. The damaged portion of the spleen is repaired using sutures.
4. If necessary, a portion of the spleen that is irreparable may be excised.
5. After the repair is complete, the surgical site is irrigated, all bleeding is controlled, and the surgical wound is closed in layers.

4. Qualifying circumstances

CPT 38115 is performed on patients who have experienced a ruptured spleen due to trauma. The procedure is typically performed by a surgeon. It is important to note that certain additional procedures, such as intraabdominal exploration, lavage, evacuation of hematoma, or similar services, may be performed in conjunction with splenorrhaphy and are considered part of the surgical package.

5. When to use CPT code 38115

CPT code 38115 should be used when a provider performs a surgical repair of a ruptured spleen, either with or without partial splenectomy. It is important to note that there is no specific code for laparoscopic splenorrhaphy, as this approach is rarely done for the types of injuries that typically require splenorrhaphy.

6. Documentation requirements

To support a claim for CPT 38115, the provider must document the following information:

• Patient’s diagnosis of a ruptured spleen
• Details of the procedure performed, including whether a partial splenectomy was performed
• Any additional procedures performed in conjunction with splenorrhaphy
• Any complications or unexpected findings during the procedure
• Details of the closure of the surgical wound

7. Billing guidelines

When billing for CPT 38115, ensure that the procedure performed is a repair of a ruptured spleen with or without partial splenectomy. It is important to note that certain additional procedures performed in conjunction with splenorrhaphy are considered part of the surgical package and should not be billed separately. It is recommended to review the specific billing guidelines of the payer to ensure accurate and appropriate billing.

8. Historical information

CPT 38115 was added to the Current Procedural Terminology system on January 1, 1990. 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 patient sustains a traumatic injury resulting in a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged area of the spleen.
2. Following a car accident, a patient is diagnosed with a ruptured spleen. The surgeon performs a splenorrhaphy with partial splenectomy to repair the damaged spleen.
3. An athlete experiences a sports-related injury that causes a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
4. During a physical altercation, a patient suffers a blow to the abdomen, resulting in a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
5. A patient involved in a fall sustains a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
6. Following a severe trauma, a patient is diagnosed with a ruptured spleen. The surgeon performs a splenorrhaphy with partial splenectomy to repair the damaged spleen.
7. An individual involved in a motorcycle accident experiences a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
8. During a sporting event, a player is injured and diagnosed with a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
9. A patient involved in a workplace accident sustains a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.
10. Following a fall from a height, a patient is diagnosed with a ruptured spleen. The surgeon performs a splenorrhaphy to repair the damaged spleen.