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A laparoscopic splenectomy, as described by CPT® Code 38120, is a minimally invasive surgical procedure aimed at the removal of the spleen. This procedure utilizes laparoscopy, which involves the use of a laparoscope—a thin, lighted tube equipped with a camera—to visualize the abdominal cavity. The operation begins with the placement of trocars, which are specialized instruments that create small incisions in the abdominal wall. Through these incisions, a pneumoperitoneum, or gas inflation of the abdominal cavity, is established to provide a working space for the surgeon. The laparoscope is then inserted to allow for exploration of the abdominal cavity. During the procedure, a retractor is used to lift the inferior aspect of the spleen, facilitating access to the surrounding structures. The splenorenal and splenocolic ligaments, which are connective tissues that anchor the spleen, are carefully divided to free the spleen from its attachments. The dissection continues in a superior and lateral direction to fully expose the posterior aspect of the splenic hilum, which is the area where blood vessels and lymphatics enter and exit the spleen. Once the spleen is completely mobilized, a surgical stapler is employed to transect the splenic hilum, effectively cutting off its blood supply. As needed, the short gastric vessels, which supply blood to the upper part of the stomach and the spleen, are also divided. After detaching the spleen, the procedure involves enlarging the incision made by the most lateral trocar to accommodate a larger trocar for specimen retrieval. A specimen retrieval bag is then inserted through this enlarged trocar site to safely contain the spleen, which is sectioned into smaller pieces for removal. Following the extraction of the spleen, a drain may be placed in the abdominal cavity to prevent fluid accumulation. The surgical instruments are then removed, the abdomen is deflated, and the trocars are taken out. Finally, the incisions are closed, completing the laparoscopic splenectomy.
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The laparoscopic splenectomy (CPT® Code 38120) is indicated for various medical conditions that necessitate the removal of the spleen. These indications may include:
The laparoscopic splenectomy procedure involves several critical steps to ensure the safe and effective removal of the spleen. The process begins with the placement of trocars through small incisions in the abdominal wall, which allows for the introduction of instruments and the laparoscope. Once the trocars are in place, a pneumoperitoneum is created by inflating the abdominal cavity with gas, providing the necessary space for the surgical procedure. The laparoscope is then inserted to visualize the internal structures of the abdomen, allowing the surgeon to assess the spleen and surrounding organs.
After the laparoscopic splenectomy, patients are typically monitored for any immediate complications. Post-procedure care may include pain management, monitoring for signs of infection, and ensuring proper recovery. Patients may be advised to avoid heavy lifting and strenuous activities for a specified period to allow for healing. A drain, if placed, will be monitored and managed as necessary. Follow-up appointments are essential to assess recovery and address any concerns that may arise during the healing process.
| Short Descr | LAPAROSCOPY SPLENECTOMY | Medium Descr | LAPAROSCOPIC SURGICAL SPLENECTOMY | Long Descr | Laparoscopy, surgical, splenectomy | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 66 - Procedures on spleen |
This is a primary code that can be used with these additional add-on codes.
| 49327 | Addon Code MPFS Status: Active Code APC N ASC N1 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) | 96547 | Add On Code MPFS Status: Active Code APC N Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; first 60 minutes (List separately in addition to code for primary procedure) | 96548 | Add On Code MPFS Status: Active Code APC N Intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) procedure, including separate incision(s) and closure, when performed; each additional 30 minutes (List separately in addition to code for primary procedure) |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 55 | Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | GJ | "opt out" physician or practitioner emergency or urgent service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| 2000-01-01 | Added | First appearance in code book in 2000. |
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