2025 ICD-10-CM code R87.615
(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 (R83-R89) Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Unsatisfactory cytologic smear of cervix; inadequate sample for interpretation.
Modifiers are not directly applicable to ICD-10 diagnostic codes. Modifiers are used with procedural codes (CPT, HCPCS).
Medical necessity for a repeat Pap smear exists when the initial sample was inadequate, preventing accurate interpretation and assessment of cervical health.This is essential for timely detection and management of precancerous or cancerous lesions.
The clinical responsibility lies with the physician or qualified healthcare professional who performs or interprets the Pap smear. This includes obtaining an adequate sample, interpreting the results, and determining the need for further investigation (e.g., repeat Pap smear, colposcopy).
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R87.615 falls under the broader category of R87 (Abnormal cytological findings in specimens from female genital organs), specifically focusing on cervical smears.
In simple words: The Pap smear test result was unsatisfactory because the sample taken was too small to be examined properly.Another Pap smear is needed to get a better sample.
This code signifies an unsatisfactory cervical cytologic smear due to an inadequate sample, preventing proper microscopic analysis and interpretation.The specimen lacked sufficient cellular material to assess for abnormalities such as atypical cells, infections, or precancerous/cancerous changes.This often necessitates a repeat Pap smear to obtain a sufficient sample.
Example 1: A 25-year-old female presents for her routine annual gynecological exam, including a Pap smear. The lab reports the smear as unsatisfactory due to insufficient cellular material. The physician orders a repeat Pap smear., A 38-year-old female with a history of abnormal Pap smears presents for follow-up. The latest Pap smear is reported as unsatisfactory because the transformation zone was not adequately visualized during sample collection. The physician performs a colposcopy to assess the cervix directly., A 50-year-old female undergoes a Pap smear as part of her routine preventative care.The lab result is unsatisfactory because the sample was obscured by excessive blood. The physician schedules a repeat Pap smear after addressing the bleeding.
*Patient demographics and relevant medical history.*Date and time of Pap smear collection.*Method of sample collection.*Reason for unsatisfactory result (e.g., inadequate sample, obscuring factors).*Physician's order for a repeat Pap smear (if applicable).*Lab report detailing the reason for the unsatisfactory result.*Physician's note documenting the clinical decision-making process.
** An unsatisfactory Pap smear does not necessarily indicate a negative result; it simply means the sample was inadequate for analysis.A repeat Pap smear is crucial to accurately evaluate cervical health and prevent delays in diagnosis and treatment of potential abnormalities.
- Revenue Code: Revenue codes will vary depending on the specific service provided (e.g., the initial Pap smear collection, the subsequent repeat test, etc.).Consult your payer's guidelines.
- RVU: RVUs are not directly assigned to ICD-10 codes; they are associated with procedural codes (CPT, HCPCS).The RVU for a repeat Pap smear would depend on the specific circumstances and the payer's fee schedule.
- Global Days : Not applicable; this is a diagnostic code, not a procedural code.
- Payment Status: Active
- Modifier TC rule: Not applicable; this is a diagnostic code.
- Fee Schedule : Not applicable. Fee schedules apply to procedural codes.
- Specialties:Obstetrics and Gynecology
- Place of Service:Office, Outpatient Clinic, Hospital