R16.1 Splenomegaly, not elsewhere classified

ICD-10-CM R16.1: Splenomegaly, not elsewhere classified

ICD-10-CM code R16.1 designates the active diagnosis of splenomegaly, not elsewhere classified, representing a finding or pathologic function situated under the parent category for hepatomegaly and splenomegaly. Clinical literature indicates splenomegaly is caused by a broad spectrum of underlying diseases. 1 2 3

Plain-language overview

Various infections, liver disease, and cancer represent multiple conditions that can cause the physical finding of splenomegaly in patients undergoing clinical evaluation. 2

Splenomegaly is a finding in patients referred to internal medical departments and has been reported in 0.3 percent of all hospital admissions within North American populations. 3

What this code represents

The active ICD-10-CM code R16.1 carries the preferred name splenomegaly, not elsewhere classified, and holds semantic types of finding and pathologic function. 1

Code R16.1 exists as a narrower concept under the parent concept R16, which encompasses hepatomegaly and splenomegaly, not elsewhere classified, within the terminology hierarchy. 1

Coding details

In a reviewed medical record study, the ICD-10 diagnosis code for splenomegaly, not elsewhere classified was utilized in 68 percent of the patients to classify the condition. 3

Documentation considerations

Medical records were reviewed for validity of the splenomegaly diagnosis, the diagnostic work-up performed, and the underlying disease determined for each patient. 3

Patients classified with idiopathic splenomegaly generally had less, and possibly insufficient, diagnostic work-up during their clinical evaluation in the reviewed medical records. 3

What the sources add

While terminology records establish the formal code hierarchy and semantic type, clinical study sources add operational context by detailing underlying disease causes and diagnostic work-up validity. 1 3

Coverage and utilization context

A public health investigation defined unresolved splenomegaly as any palpable splenomegaly after arrival among refugees with a diagnosis of splenomegaly before or after arrival. 2

Sources

1. ICD-10-CM R16.1 terminology record — National Cancer Institute Enterprise Vocabulary Services; accessed 2026-07-27.
2. Unresolved Splenomegaly in Recently Resettled Congolese Refugees... — cdc.gov; accessed 2026-07-27.
3. Splenomegaly – Diagnostic validity, work-up, and underlying causes — pmc.ncbi.nlm.nih.gov; accessed 2026-07-27.