2025 ICD-10-CM code R87.613
High grade squamous intraepithelial lesion (HGSIL) detected on a cervical cytology smear.
Medical necessity for using R87.613 is established when an HGSIL is identified on a cervical cytology smear, indicating a potential precancerous condition requiring further evaluation and management.
Clinicians, including gynecologists, family practitioners, and other healthcare providers who perform Pap smears and manage abnormal cervical cytology results, are responsible for using this code appropriately. This includes accurate documentation, follow-up recommendations, and appropriate communication with the patient.
In simple words: The Pap smear results show abnormal cell changes on the cervix called high-grade squamous intraepithelial lesion (HGSIL). This might be precancerous and needs follow-up.
High grade squamous intraepithelial lesion (HGSIL) identified on a cytologic smear of the cervix. This indicates abnormal changes in the cervical cells that may be precancerous.
Example 1: A 30-year-old female patient undergoes a routine Pap smear, and the cytology report returns with a diagnosis of HGSIL. Colposcopy is recommended for further evaluation., A 25-year-old female patient has a history of abnormal Pap smears. Her recent Pap smear again shows HGSIL, and she undergoes a loop electrosurgical excision procedure (LEEP)., A 45-year-old female presents with postcoital bleeding. A Pap smear is performed, revealing HGSIL. Further workup includes a colposcopy and biopsy.
Documentation should include the cytology report indicating HGSIL, details of the Pap smear procedure, relevant clinical findings, and planned follow-up or treatment.
** This code is specific to cytologic findings and does not apply to histologic confirmation of HGSIL.
- Specialties:Gynecology, Family Medicine, Primary Care
- Place of Service:Office, Outpatient Hospital, Clinic