Find comprehensive information on splenomegaly diagnosis, including ICD-10 codes (R16.1, R16.2), clinical documentation improvement tips, differential diagnosis considerations, and healthcare resources. Learn about causes of enlarged spleen, symptoms, treatment options, and the role of pathology and radiology in splenomegaly evaluation. This resource provides guidance for physicians, nurses, and medical coders seeking accurate and up-to-date information on spleen enlargement.
Also known as
Splenomegaly
Enlarged spleen.
Hypersplenism
Overactive spleen, often with splenomegaly.
Congenital splenomegaly
Spleen enlargement present from birth.
Fever and other symptoms
May include splenomegaly as a finding with various illnesses.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is splenomegaly due to a specific underlying condition?
Yes
Is it due to portal hypertension?
No
Is hypersplenism documented?
When to use each related code
| Description |
|---|
| Enlarged spleen |
| Hypersplenism |
| Portal hypertension |
Coding splenomegaly without documenting the underlying cause leads to inaccurate coding and potential DRG misassignment.
Lack of clear clinical evidence supporting splenomegaly diagnosis may cause coding errors and compliance issues.
Incorrectly coding hypersplenism as splenomegaly or vice versa leads to inaccurate reporting and affects reimbursement.
Patient presents with complaints suggestive of splenomegaly. Symptoms include left upper quadrant pain, abdominal fullness, early satiety, and fatigue. Physical examination reveals palpable splenic enlargement extending [Number] cm below the left costal margin. Differential diagnosis includes infectious mononucleosis, portal hypertension, lymphoma, leukemia, and other hematologic disorders. Complete blood count (CBC) with differential, comprehensive metabolic panel (CMP), and peripheral blood smear ordered to evaluate for cytopenias, liver function abnormalities, and atypical cells. Abdominal ultrasound or CT scan with and without contrast will be performed to assess splenic size, morphology, and identify any associated abnormalities. Initial management includes monitoring symptoms and addressing underlying causes. Patient education provided regarding avoidance of contact sports due to risk of splenic rupture. Follow-up scheduled to review laboratory and imaging results and discuss further management based on etiology of splenomegaly. ICD-10 code R78.89 (Other specified abnormal findings of spleen) may be applicable, pending further investigation. Medical necessity for imaging and laboratory studies documented.