Hypersplenism

Hypersplenism is a syndrome characterized by splenomegaly, peripheral cytopenias (anemia, leukopenia, or thrombocytopenia), and compensatory bone marrow hyperplasia. The enlarged spleen prematurely destroys blood cells, leading to these deficiencies.

Assign this code when documentation explicitly states "hypersplenism" as the diagnosis. This condition is often secondary to other underlying diseases, such as portal hypertension, chronic infections, or autoimmune disorders, but this code specifically captures the splenic dysfunction.

• Do not code this for isolated splenomegaly without evidence of increased splenic activity and cytopenias.
• Review documentation for the underlying cause of hypersplenism; code the primary condition first if known and applicable.
• Be mindful of the Excludes1 notes to avoid incorrect co-coding with specific types of splenomegaly or neutropenia.