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2025 ICD-10-CM code R87.620

Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US).

Adhere to the official ICD-10-CM coding guidelines published by CMS. Use R87.620 only when ASC-US is identified in a vaginal smear and when the findings are not definitive enough to warrant other diagnoses. Proper selection of additional codes is needed if other abnormalities are found.

Modifiers are not applicable to ICD-10 codes like R87.620. Modifiers are used with procedural codes to specify the circumstances of the service provided.

Medical necessity for a Pap smear with subsequent coding of R87.620 depends on the patient's age, risk factors (e.g., sexual history, smoking, family history of cervical cancer), and prior screening results.Abnormal findings necessitate further evaluation to rule out precancerous or cancerous lesions.

The clinical responsibility involves obtaining the vaginal smear, performing the cytological examination, and interpreting the results.This often involves collaboration between the physician, cytotechnologist, and potentially a pathologist. Follow-up care is determined based on the findings.

IMPORTANT Related codes include those specifying other abnormal cytological findings from the vagina (R87.621-R87.629), cervix (R87.610-R87.619), or other female genital organs (R87.69).Consider also codes for specific HPV infections (R87.811, R87.821) or neoplasias if confirmed.

In simple words: This code means that an abnormal cell was found during a vaginal smear test, but doctors aren't sure what it means yet. More tests may be needed to figure out if there is a problem.

This ICD-10-CM code signifies atypical squamous cells of undetermined significance (ASC-US) identified during a cytologic examination of a vaginal smear.The findings are considered atypical but not definitively indicative of a high-grade squamous intraepithelial lesion (HSIL) or malignancy. Further investigation may be necessary to determine the underlying cause.

Example 1: A 35-year-old female presents for a routine Pap smear.The results reveal atypical squamous cells of undetermined significance (ASC-US).Further testing (e.g., colposcopy, HPV testing) is recommended., A 40-year-old female with a history of abnormal Pap smears undergoes a follow-up examination.The vaginal smear again shows ASC-US.The physician orders a repeat Pap smear in 6 months, and considers further evaluation., A 28-year-old female presents with vaginal bleeding and discomfort.A vaginal smear is performed to evaluate for infection or pathology. The cytology reveals ASC-US, which prompts a colposcopy to further investigate potential abnormalities.

Complete documentation should include the date of the Pap smear, the method of collection, the laboratory report with the specific cytological findings (ASC-US), any clinical signs or symptoms noted,and the physician’s plan for follow-up or further investigation.

** Always cross-reference R87.620 with the complete laboratory report and clinical findings.Accurate coding requires meticulous documentation to support the diagnosis.

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