2025 ICD-10-CM code R87.623
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs, and abnormal clinical and laboratory findings - Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
High-grade squamous intraepithelial lesion (HGSIL) on a vaginal cytologic smear.
Medical necessity for further investigation (colposcopy, biopsy) after detection of HGSIL on a vaginal smear is established based on the high risk of progression to invasive cancer if left untreated.Early detection and intervention are crucial for preventing cervical cancer and improving patient outcomes.
The clinical responsibility involves obtaining a complete medical history, performing a thorough physical examination, interpreting the cytological findings in context with other clinical information, and determining the appropriate management strategy, which may involve further investigations like colposcopy and biopsy.The physician is responsible for communicating the findings to the patient, counseling on implications and treatment options, and coordinating any necessary referrals or follow-up care.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R87.623 falls under the broader category of R87.62 (High-grade squamous intraepithelial lesion on cytologic smear).
In simple words: The Pap smear shows some abnormal cells in the vagina that are precancerous.These cells are not cancerous yet, but need further evaluation by a doctor.
This ICD-10-CM code signifies the presence of high-grade squamous intraepithelial lesion (HGSIL) detected on a cytological examination of a vaginal smear.HGSIL represents moderate to severe precancerous cellular changes in the vagina. This finding requires further investigation to determine the extent and nature of the lesion and to exclude the presence of invasive cancer.The diagnosis is based on microscopic examination of cells obtained through a Pap smear or other appropriate cytological sampling technique.It is crucial to differentiate HGSIL from low-grade squamous intraepithelial lesions (LSIL) and other conditions that may present with similar cytological findings.
Example 1: A 35-year-old female presents for a routine Pap smear.The results show HGSIL on the vaginal smear.Colposcopy and biopsy are recommended to further evaluate the lesion., A 42-year-old female with a history of abnormal Pap smears undergoes a colposcopy, which reveals a suspicious lesion on the vagina.Biopsy confirms HGSIL. Further treatment is necessary to prevent progression to cancer., A 28-year-old female with abnormal vaginal bleeding undergoes a Pap smear and a biopsy.The results show HGSIL,indicating the presence of precancerous cells on the vagina.The patient undergoes further testing to determine the course of treatment.
Detailed documentation should include the date of the Pap smear, the type of specimen collected (vaginal smear), the microscopic description of the HGSIL, the location of the lesion, and the results of any additional testing, such as colposcopy and biopsy findings.
** HGSIL on a vaginal smear often requires a multidisciplinary approach, involving collaboration between the gynecologist, pathologist, and potentially other specialists based on the extent of disease or presence of comorbidities.
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Pathology
- Place of Service:Office, Outpatient clinic, Hospital