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2025 ICD-10-CM code N89.0

Mild vaginal dysplasia, also known as vaginal intraepithelial neoplasia (VAIN) grade I.

Accurate coding of N89.0 requires confirmation of the diagnosis through histopathological examination.The level of dysplasia should be clearly specified in the documentation.This code should not be used if there is evidence of moderate or severe dysplasia, carcinoma in situ, or other related conditions.

Medical necessity for coding N89.0 is established by the presence of confirmed histopathological evidence of mild vaginal dysplasia.Regular screening and follow-up are essential to monitor for progression and to provide appropriate management.

The clinical responsibility for diagnosing and managing mild vaginal dysplasia rests primarily with gynecologists and other healthcare professionals specializing in women's health.This involves conducting a thorough examination, obtaining tissue samples for histopathological analysis, and providing appropriate counseling and follow-up care.

IMPORTANT:Related codes include N89.1 (moderate vaginal dysplasia), N89.2 (severe vaginal dysplasia), and D07.2 (carcinoma in situ of the vagina).The choice of code depends on the severity of the dysplasia as confirmed by histopathological examination.R87.62 (abnormal cytological findings in specimens from vagina) may be used in conjunction with N89.0 if cytology findings support the diagnosis, but histologic confirmation is required for definitive coding.

In simple words: This code describes a mild, early stage of abnormal cell growth in the vagina. It's not cancer, but it's important to monitor because it could potentially develop into cancer.A doctor needs to confirm the diagnosis with a tissue sample.

N89.0 in the ICD-10-CM classification system represents mild vaginal dysplasia.This refers to a precancerous condition characterized by abnormal cell growth in the vaginal lining.It is considered a low-grade lesion of the vagina and is less severe than moderate or severe dysplasia.Histological confirmation is necessary for accurate diagnosis and coding.This code excludes other conditions such as inflammation, infections, or carcinoma in situ.

Example 1: A 35-year-old female patient presents with abnormal Pap smear results.Colposcopy reveals mild dysplasia in the vagina. A biopsy confirms the diagnosis of VAIN I.Code N89.0 is assigned., A 28-year-old female presents for routine gynecological examination.During the examination, the physician notes subtle changes in the vaginal epithelium.A biopsy is performed, revealing mild vaginal dysplasia (VAIN I). The diagnosis of N89.0 is recorded., A 42-year-old woman with a history of HPV infection undergoes regular cervical cancer screening.Her Pap smear shows mild abnormalities. Subsequent colposcopy and biopsy reveal mild vaginal dysplasia (N89.0).

Complete documentation should include the patient's history, physical examination findings, results of Pap smears and colposcopy, histopathological report confirming the diagnosis of mild vaginal dysplasia, and any additional relevant findings.The documentation should clearly indicate the absence of moderate or severe dysplasia or carcinoma in situ.

** The 7th character is not applicable to this code.This code is specific to mild dysplasia and excludes other conditions with similar symptoms or findings.Always ensure the documentation accurately reflects the severity of the dysplasia and appropriate clinical findings.

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