2025 ICD-10-CM code N89.3
Dysplasia of vagina, unspecified.
Medical necessity is established by the presence of signs, symptoms, or abnormal findings suggestive of vaginal dysplasia. The diagnosis needs to be confirmed with histopathological examination.The medical necessity for any subsequent treatments (such as ablation or excision) will depend on the type and grade of dysplasia found.
Diagnosis and management of this condition falls under the purview of gynecologists or other healthcare professionals specializing in women's reproductive health. They are responsible for conducting necessary examinations, ordering diagnostic tests like biopsies, and formulating an appropriate treatment plan based on the severity and type of dysplasia identified.
In simple words: Abnormal cell changes in the vagina that are not clearly defined as mild, moderate, or severe.
Dysplasia of vagina, unspecified. This code represents a diagnosis of dysplasia in the vagina where the specific degree or type of dysplasia (mild, moderate, severe) is not documented or specified.
Example 1: A patient presents with abnormal vaginal bleeding. A biopsy is taken, and the pathology report indicates vaginal dysplasia, but does not specify the severity.N89.3 is used until further details are available., A routine Pap smear shows abnormal cells. A colposcopy and biopsy are performed. The pathology report describes vaginal dysplasia without specifying the grade.N89.3 is applied., A patient has a history of HPV. During a pelvic exam, the physician notes an abnormal area on the vaginal wall. A biopsy is performed, but the results only indicate "vaginal dysplasia" with no further classification. N89.3 would be used as a placeholder until more information is obtained.
Documentation should include details of the patient's presentation, relevant history (such as HPV status), findings from the pelvic exam and colposcopy (if performed), and the pathology report indicating dysplasia. The absence of a specific grade in the pathology report should also be clearly documented.
- Specialties:Gynecology, Obstetrics
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital