Complete ICD-10-CM coding and documentation guide for icd-10 coding for enlarged spleen includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Enlarged Spleen
Use ICD-10 code R16.1 for splenomegaly, not elsewhere classified, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Use when splenomegaly is due to hypersplenism.
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
The ICD-10 code for an enlarged spleen not elsewhere classified is R16.1. It is used when no underlying cause is identified.
Splenomegaly should be documented with spleen size and confirmation method, such as imaging or detailed physical exam.