ICD Code R16.1

ICD code R16.1 is splenomegaly, which means an enlarged spleen that is not classified under any other specific condition.

1. Clinical evidence of an enlarged spleen detected through physical examination or imaging studies

2. Absence of a more specific underlying cause identified for the splenomegaly

3. No documentation of associated hematologic, infectious, or malignant conditions that would warrant a more specific code

4. Patient may present with symptoms such as abdominal fullness, early satiety, or left upper quadrant discomfort

5. Laboratory findings may include cytopenias or abnormal liver function tests, but without a definitive diagnosis explaining the splenomegaly

6. The enlargement is not attributable to trauma, congenital anomalies, or other classified disorders

Relevant CPT codes that may be used to treat ICD code R16.1 include:

- 38206: Diagnostic percutaneous aspiration of bone marrow

- 38221: Bone marrow biopsy, needle or trocar

- 49080: Abdominal paracentesis (diagnostic or therapeutic)

- 49320: Laparoscopy, abdominal, peritoneal, diagnostic

- 47135: Liver allotransplantation

- 47120: Partial hepatectomy

- 38100: Splenectomy, total (separate procedure)

- 38101: Splenectomy, partial (separate procedure)

- 76700: Ultrasound, abdominal, real time with image documentation; complete

- 74177: CT abdomen and pelvis with contrast

These CPT codes are commonly associated with the evaluation and management of R16.1.

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