2025 ICD-10-CM code R87.616
(Valid) Effective Date: N/A Abnormal findings on examination of other body fluids, substances and tissues - Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89) 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Satisfactory cervical smear but lacking transformation zone component. This indicates a normal Pap smear result where the sample collected did not include cells from the transformation zone of the cervix.
Medical necessity for a Pap smear is determined by established guidelines for cervical cancer screening based on age and risk factors. When a Pap smear comes back as R87.616, the decision to repeat the test is guided by a clinical assessment of the patient's individual risk factors for cervical cancer. Medical necessity for a repeat test would be supported by documentation of these factors.
It is crucial for the clinician to interpret the cytology report in conjunction with the patient's clinical history and perform a risk assessment to determine if and when a repeat Pap smear is necessary. The absence of T-zone cells does not automatically warrant a repeat Pap smear, particularly in patients with a low risk of cervical cancer. However, additional factors, such as age, previous abnormal Pap smear results, history of HPV infection, or other risk factors, may guide the decision to repeat testing sooner than the routine screening interval.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R87 Abnormal findings in specimens from female genital organsR87.6 Abnormal cytological findings in specimens from cervix uteriR87.61 Satisfactory cervical smear but lacking transformation zoneR87.616 Satisfactory cervical smear but lacking transformation zone
In simple words: The Pap smear was normal, but the sample didn't include cells from a key part of the cervix.
Satisfactory cervical smear but lacking transformation zone component. This generally refers to a Pap smear where the sample collected was adequate for evaluation, showing no signs of cancerous or precancerous cells, but did not contain cells from the transformation zone (T-zone), a crucial area of the cervix where abnormal cell growth is most likely to occur.
Example 1: A 30-year-old woman undergoes a routine Pap smear, and the result is reported as "satisfactory for evaluation but limited by the absence of endocervical/transformation zone component." She has no prior history of abnormal Pap smears and is HPV negative. In this case, the clinician may decide to repeat the test at the regular screening interval (e.g. 3 years)., A 45-year-old woman with a history of an abnormal Pap smear (ASCUS) in the past has a Pap smear result of "satisfactory for evaluation but limited by the absence of endocervical/transformation zone component."Although the current Pap is normal, given her history, the physician may recommend a repeat Pap smear in 6-12 months or HPV testing to ensure there are no underlying cervical abnormalities., A 25-year-old woman who has never had a Pap smear has one performed, which is reported as R87.616. In this scenario, given it is her first screening, a repeat Pap smear would likely be recommended sooner than the routine screening interval to ensure adequate sampling of the transformation zone.
Clinical documentation should clearly indicate the reason for the Pap smear, the result, and any relevant clinical findings.If the T-zone component is absent, the report should mention it. Subsequent decisions regarding repeat testing and their rationale should be documented.
** This code is informative for clinicians and aids in determining the appropriate follow-up. However, it does not represent a diagnosis in itself but rather a characteristic of the collected specimen.
- Specialties:Obstetrics and Gynecology, Family Medicine, Internal Medicine
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Clinic