2025 ICD-10-CM code R87.89
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89) 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Other abnormal findings in specimens from female genital organs. This code encompasses abnormal results from various tests performed on samples taken from the female genital tract, excluding those already classified elsewhere.
Medical necessity for using this code is established by the presence of abnormal findings in a specimen from the female genital organs that cannot be classified under a more specific diagnosis. The documentation should support the need for the diagnostic tests performed and the ongoing clinical evaluation.
The clinician is responsible for ordering appropriate tests, interpreting the abnormal findings, and determining the necessary follow-up based on the specific clinical context.This may involve additional diagnostic testing, consultation with a specialist, or initiating treatment.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89)
In simple words: This code indicates that a test result from a sample taken from a woman's reproductive organs is abnormal, but it doesn't specify the exact problem. Further investigation is typically needed.
This ICD-10-CM code represents other abnormal findings in specimens from female genital organs. It includes abnormal findings in secretions and smears from the cervix uteri, vagina, and vulva, as well as abnormal chromosomal findings.It excludes abnormal findings on antenatal screening of the mother (O28.-) and diagnostic abnormal findings classified elsewhere.
Example 1: A Pap smear reveals atypical squamous cells of undetermined significance (ASCUS).After further investigation, no specific diagnosis is found. R87.89 would be used to document the abnormal Pap smear findings when a more definitive diagnosis is not yet determined., A vaginal swab culture returns with unusual bacterial growth, but the organisms are not specifically pathogenic and don't meet the criteria for any definable infection. R87.89 can be used to document the unusual findings when no specific diagnosis can be made., A biopsy of the cervix reveals mild dysplasia that does not require immediate intervention. R87.89 would be appropriate if the clinical picture and other test results do not point to a more specific diagnosis, such as cervical intraepithelial neoplasia (CIN).
Documentation should include details about the specimen collected (e.g., Pap smear, cervical biopsy, vaginal swab), the specific abnormal findings, and any further diagnostic procedures performed.The rationale for using R87.89 should also be documented, especially when a definitive diagnosis is not yet established.
** R87.89 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Further investigation is often required to arrive at a definitive diagnosis. As of December 1st, 2024, this information is current.However, coding guidelines and medical practices can change, so it is crucial to verify the most up-to-date information with official resources.
- Specialties:Gynecology, Obstetrics, Family Medicine, Pathology
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Independent Clinic