2025 ICD-10-CM code R87
(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 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Abnormal findings in specimens from female genital organs.
Medical necessity for coding R87 is established by the presence of abnormal findings on examination of specimens from the female genital organs. This warrants further investigation to determine the underlying cause and appropriate management.The rationale for further testing should be documented.
The clinical responsibility for this code rests with the healthcare professional who orders and interprets the results of the tests on specimens from the female genital organs. This could be an obstetrician-gynecologist, family physician, or other qualified healthcare professional depending on the clinical context.They are responsible for further investigation and management of the abnormal findings.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R87
In simple words: This code is used when a test of fluids or samples from a woman's vagina, cervix, or vulva shows something is not normal, but doctors don't yet know what the problem is.
This code encompasses abnormal results from examinations of specimens obtained from the female genital organs (cervix, vagina, vulva).It includes findings such as abnormal secretions, smears, and other analyses that do not lead to a more specific diagnosis.The code is used when the abnormal finding is not further specified or when the cause is unknown after investigation.
Example 1: A Pap smear reveals atypical squamous cells of undetermined significance (ASCUS), requiring further testing to determine the cause., A vaginal swab shows evidence of inflammation, but the causative agent is not identified through standard culture techniques., A patient presents with abnormal vaginal bleeding, and a biopsy of the cervix reveals an abnormality that requires more detailed testing to confirm a diagnosis (e.g., cancer versus benign lesion).
Detailed documentation is required, including the specific type of test performed (e.g., Pap smear, vaginal culture, biopsy), the date of the test, the specific abnormalities observed, and any additional clinical findings related to the patient’s condition.The results of any subsequent testing or procedures should also be documented.
** This code is often used as a placeholder until further investigation is completed and a definitive diagnosis is obtained. It is crucial to avoid using this code indefinitely; continuous use without a proper diagnosis or additional investigation may lead to coding errors and billing issues.
- Payment Status: Active
- Specialties:Obstetrics and Gynecology, Family Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center