General Surgery Coding Alert

Question: A patient has undergone en bloc splenectomy. This is the only procedure the surgeon performs at the time. How can I report this? According to CPT, I shouldn't claim 38102 as a stand-alone service.


Illinois Subscriber

Answer: The term -en bloc- means -to remove as a whole.- Therefore, an en bloc splenectomy is equivalent to a total splenectomy.

For a total (or en bloc) splenectomy performed as a separate procedure, you should report only 38100 (Splenectomy; total [separate procedure]). Similarly, you should report 38101 (- partial [separate procedure]) for a partial splenectomy performed singly and not with any other, related procedure.

You are correct that you should not report add-on procedure +38102 (- total, en bloc for extensive disease, in conjunction with other procedure [list in addition to code for primary procedure]) alone.

Instead, you should report 38102 if the surgeon performs a total splenectomy with another procedure. In such cases, however, the splenectomy must be medically necessary (for disease of the spleen) and not merely incidental to the primary procedure. You cannot separately report incidental splenectomy performed at the same time as another, related procedure.