Hepatomegaly

This code signifies an enlarged liver, a non-specific finding that can indicate various underlying medical conditions. It is a physical sign or symptom, not a definitive diagnosis of a specific liver disease.

Use this code when documentation explicitly states "hepatomegaly" without further specification of the cause. This often occurs during initial evaluations or when the etiology of the liver enlargement is still under investigation. Supporting documentation includes physical exam findings, imaging reports (e.g., ultrasound, CT scan) noting an enlarged liver, or physician notes.

• Always code the underlying cause of hepatomegaly if known and documented.
• This code is typically a secondary diagnosis unless no definitive cause can be determined.
• Do not use this code if a more specific diagnosis, such as fatty liver disease or cirrhosis, is documented as the cause of the enlarged liver.