Chronic congestive splenomegaly

This code signifies an enlarged spleen resulting from long-standing venous congestion, often secondary to portal hypertension or heart failure. The chronic nature implies a persistent and often progressive condition affecting splenic function and size.

Apply this code when documentation explicitly states "chronic congestive splenomegaly" or describes an enlarged spleen due to chronic venous congestion. Supporting documentation may include imaging reports (e.g., ultrasound, CT scan) noting splenomegaly with evidence of portal hypertension or chronic cardiac conditions.

• Differentiate from acute splenomegaly (R16.1), which is typically sudden onset and not due to chronic congestion.
• Always code the underlying cause of the chronic congestion (e.g., K74.60 for portal hypertension, I50.x for heart failure) as the primary diagnosis if known and clinically appropriate.
• Ensure the medical record clearly indicates the chronicity and the congestive nature of the splenomegaly.