ICD 10 Coding Alert

Question: I have a report stating a patient was evaluated for hepatomegaly via ultrasound. The patient originally went to their general practitioner (GP) with complaints of abdominal pain, nausea and vomiting, and fatigue. Following a physical examination, the GP referred the patient to our radiology practice for an ultrasound of the patient’s liver. After interpreting the results of the ultrasound, the radiologist documented their findings as hepatomegaly.

What codes do I need to report this encounter?

Iowa Subscriber

Answer: You’ll need two codes to report this encounter. You’ll assign 76705 (Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)) to report the ultrasound of the patient’s liver. You’ll then assign R16.0 (Hepatomegaly, not elsewhere classified) to report the diagnosis.

The radiologist performed an ultrasound only on the liver to evaluate the hepatomegaly. The descriptor for 76705 indicates the code is designated for a limited abdominal ultrasound of a certain area or specific body structure. You should also double-check the written report in the patient’s record to ensure that images were permanently recorded, as they are required according to the AMA CPT^® guidelines preceding the diagnostic ultrasound section of the code set.

Hepatomegaly is an enlarged liver, and several symptoms can manifest to indicate the condition. Symptoms of hepatomegaly include fatigue, abdominal pain, nausea and vomiting, and yellowing of the skin and white of the eyes.

When you search for hepatomegaly in the ICD-10-CM Alphabetic Index, you’ll be redirected to Hypertrophy, liver. Under Hypertrophy > liver, you’ll find R16.0, which you can verify in the Tabular List.

Since the provider documented the diagnosis of hepatomegaly not otherwise specified (NOS), R16.0 is the correct diagnosis code to use.