In simple words: Moderate vaginal dysplasia means some abnormal cells have been found in the lining of the vagina. It's not cancer, but it could become cancer if not watched closely. A doctor will need to do a test to confirm this diagnosis.

N89.1, Moderate vaginal dysplasia, refers to a moderate degree of abnormal cell growth in the lining of the vagina.It is a precancerous condition that requires close monitoring and may progress to more severe dysplasia or even cancer if left untreated.Histological confirmation is necessary for diagnosis.This code is used when moderate dysplasia is confirmed through biopsy.

Example 1: A 35-year-old woman undergoes a colposcopy and biopsy following an abnormal Pap smear. The biopsy reveals moderate dysplasia of the vaginal epithelium, consistent with VAIN II., A 42-year-old woman presents with vaginal bleeding and undergoes a diagnostic workup.Biopsy results confirm moderate vaginal dysplasia, prompting further monitoring and follow-up., A 28-year-old woman with a history of HPV infection undergoes regular screening.A biopsy reveals moderate vaginal dysplasia, leading to closer monitoring and potential treatment strategies.

* Complete history and physical examination* Results of Pap smear and other relevant cytological testing* Histopathological examination report from vaginal biopsy, confirming the diagnosis of moderate dysplasia* Documentation of clinical findings supporting the diagnosis* Physician’s documentation specifying the severity of dysplasia.

** This code should not be used if abnormal cytological findings lack histological confirmation.Always refer to the latest official ICD-10-CM coding guidelines for the most up-to-date information.