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v1.0.0
ICD-10 Guide
DiagnosesSplenectomy

Splenectomy

ICD-10 Coding for Splenectomy(D73.0, D73.1)

PRIMARY SPECIALTYGeneral Surgery
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Splenectomy?
Essential facts and insights about Splenectomy

Key Clinical Considerations:

  • Splenomegaly, recurrent infections, thrombocytopenia
  • Complete blood count (CBC), imaging studies (ultrasound, CT scan), bone marrow biopsy if indicated
  • Abdominal tenderness, palpable spleen, signs of infection

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history, indication for surgery, operative report, post-operative care plan
  • ICD-10-PCS codes for surgical procedures, CPT codes for surgical services
  • Operative note detailing the procedure, pre-operative and post-operative diagnoses

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding splenectomy versus other abdominal surgeries.
  • Common errors include incorrect coding of complications or failure to document pre-existing conditions.

Code Exclusions

Important Exclusions

  • Conditions such as splenic abscess or splenic rupture may require different coding.
  • Alternative codes may apply for laparoscopic versus open splenectomy.

Related ICD-10 Codes

Primary Codes
D73.1
Splenic cyst
D73.9
Disorder of spleen, unspecified
Z90.1
Acquired absence of spleen
Differential Codes
R16.1
R16.1
when splenomegaly is present without a specific underlying condition.
D73.2
D73.2
for acute presentations.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

General Surgery

Specialty Applications

  • Patients with hematological disorders, trauma patients, and those with splenic tumors.
  • General surgical settings, trauma centers, and outpatient surgical facilities.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include patient history, indication for splenectomy, and detailed operative report.

Billing considerations?

Ensure correct coding of diagnosis and procedure; check for any bundled services.