2025 ICD-10-CM code R87.612
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs, and abnormal clinical and laboratory findings - Abnormal cytological findings in specimens from cervix uteri Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Low-grade squamous intraepithelial lesion (LGSIL) detected on a cervical cytologic smear.
Modifiers may be applicable depending on the circumstances of the service, such as the place of service or the type of procedure performed.Refer to the current modifier guidelines.
The medical necessity for coding R87.612 rests on the presence of abnormal cervical cytology indicative of LGSIL. This necessitates further investigation, monitoring, and potential treatment to prevent progression to more severe conditions or cancer.
The clinical responsibility lies with the physician or healthcare provider who performs the Pap smear, interprets the results, and provides any necessary follow-up care, such as further testing or referral to a specialist.This might include a gynecologist, pathologist, or oncologist depending on the specific circumstances.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R87.61-
In simple words: This code means an abnormal Pap smear showed some changes in the cells of the cervix. These changes are considered low-grade and are not cancer, but they need to be monitored because they could potentially develop into cancer.
This ICD-10-CM code signifies the presence of a low-grade squamous intraepithelial lesion (LGSIL) identified during a cytological examination of a cervical smear.LGSIL represents a precancerous condition characterized by abnormal cell growth on the surface of the cervix. The diagnosis is established through microscopic analysis of the cervical cells obtained via Pap smear.This code is used when the cytology findings indicate LGSIL, and no more specific diagnosis is available after investigation.It's crucial to differentiate LGSIL from other cervical abnormalities like ASC-US, ASC-H, HGSIL, and cancerous lesions, each with its own specific ICD-10 code.Appropriate documentation should detail the microscopic findings and justify the choice of this code, excluding other possibilities.
Example 1: A 25-year-old female presents for a routine Pap smear as part of her annual gynecological exam. The cytology report reveals LGSIL findings. This code accurately reflects the abnormal findings., A 38-year-old female had a previous abnormal Pap smear (ASC-H). A repeat Pap smear is performed showing LGSIL.R87.612 would be used to report this finding., A 42-year-old female undergoes a colposcopy following an abnormal Pap smear.The biopsy results are negative for cancer but show LGSIL, which is documented with R87.612.
* Complete patient demographics.* Date of service.* Detailed cytology report with microscopic description of the LGSIL findings.* Documentation supporting the exclusion of other cervical abnormalities.* Physician's interpretation and diagnosis.* Follow-up plan if any.
** Always refer to the most up-to-date ICD-10-CM coding guidelines and official resources for accurate coding practices.This information is for guidance only and should not be considered a substitute for professional medical coding advice.
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- Global Days : Not applicable.
- Payment Status: Active
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- Specialties:Gynecology, Pathology, Oncology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center