Hepatomegaly, not elsewhere classified
ICD-10 R16.0 is a billable code used to indicate a diagnosis of hepatomegaly, not elsewhere classified.
Hepatomegaly, or enlargement of the liver, is a clinical finding that can indicate a variety of underlying conditions. It is characterized by an increase in liver size beyond the normal range, which can be detected through physical examination or imaging studies such as ultrasound, CT, or MRI. Symptoms associated with hepatomegaly may include abdominal discomfort, fullness, or pain, jaundice, and signs of liver dysfunction. Common causes of hepatomegaly include liver diseases such as hepatitis, fatty liver disease, cirrhosis, and liver tumors, as well as systemic conditions like congestive heart failure and metabolic disorders. The diagnosis of hepatomegaly is often made incidentally during imaging for other reasons, and further evaluation is typically required to determine the underlying cause. Laboratory findings may include elevated liver enzymes, bilirubin levels, and abnormal coagulation profiles, which can help guide the diagnostic process. Accurate coding of hepatomegaly is essential for proper patient management and reimbursement.
Detailed history and physical examination notes, including symptoms, lab results, and imaging findings.
Patients presenting with abdominal pain, jaundice, or incidental findings on imaging.
Ensure that the underlying cause of hepatomegaly is documented to avoid coding errors.
Acute care notes that capture the patient's presenting symptoms, vital signs, and any immediate lab results.
Patients with acute abdominal pain or signs of liver failure presenting to the emergency department.
Document any acute changes in liver function tests and the need for urgent imaging.
Used to evaluate hepatomegaly and assess liver structure.
Document the indication for the ultrasound and findings related to hepatomegaly.
Ensure that the ultrasound report is linked to the diagnosis of hepatomegaly.
Hepatomegaly is a medical term specifically used to describe the enlargement of the liver, which can be detected through imaging or physical examination. Liver enlargement may refer to the same condition but can also encompass other factors affecting liver size.
