2025 ICD-10-CM code R87.614

Cytologic evidence of malignancy on smear of cervix.

Use this code for cytologic evidence of malignancy on a cervical smear when a definitive diagnosis has not yet been established through further investigation, such as biopsy. Do not use this code if a confirmed diagnosis of cervical cancer is available.

Medical necessity for the Pap smear leading to the R87.614 code would be based on the patient's age, history, and risk factors for cervical cancer.Further diagnostic procedures are medically necessary to rule out or confirm a diagnosis of cancer.

The clinician ordering and interpreting the cervical smear is responsible for documenting the findings and ordering further investigations to establish a definitive diagnosis.

In simple words: A cervical smear test has shown some abnormal cells that could be cancerous. More tests are needed to be sure.

This code indicates the presence of abnormal cells on a cervical smear, suggestive of malignancy.It represents a cytological finding, not a confirmed diagnosis of cancer. Further investigation, such as a biopsy, is required for definitive diagnosis.

Example 1: A patient undergoes a routine Pap smear as part of a well-woman exam.The cytology report returns with R87.614, indicating suspicious cells.A colposcopy and biopsy are subsequently performed., A patient presents with abnormal vaginal bleeding. A Pap smear is performed, and the cytology report indicates R87.614. Further imaging and diagnostic procedures are ordered to assess for cervical cancer., During a follow-up visit for HPV infection, a repeat Pap smear shows R87.614.The patient is referred to a gynecologic oncologist for further evaluation.

Documentation should include the results of the cervical smear, details about the sample collection, and any associated signs or symptoms.Subsequent diagnostic procedures and their results, including biopsies, should also be documented.

  • Specialties:Family Medicine, Obstetrics and Gynecology, Gynecologic Oncology, Pathology
  • Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Independent Clinic,Federally Qualified Health Center
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