2025 ICD-10-CM code R87.618

This code signifies other abnormal cytological findings on specimens from the cervix uteri not otherwise specified.

Use this code only when other more specific codes, such as those for specific abnormalities or precancerous conditions, are not applicable.Ensure the cytology report supports the use of R87.618.

Medical necessity for using this code is established when a Pap smear reveals abnormal cytological findings on specimens from the cervix uteri, that are not specific enough for another, more definitive code and further investigation is needed.

The clinician is responsible for ordering appropriate follow-up tests and procedures based on the cytological findings and the patient's clinical presentation. This may include colposcopy, biopsy, or referral to a specialist for further evaluation.

In simple words: This code indicates that the lab results from your cervical screening show some abnormal cell changes that need further investigation. It does not necessarily mean you have cancer, but more tests may be needed to determine the cause of these changes.

This ICD-10-CM code, R87.618, designates other abnormal cytological findings identified in specimens taken from the cervix uteri, excluding specific diagnoses like atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells, rule out high-grade squamous intraepithelial lesion (ASC-H), low-grade squamous intraepithelial lesion (LGSIL), high-grade squamous intraepithelial lesion (HGSIL), and cytologic evidence of malignancy.It also excludes unsatisfactory smears, satisfactory smears lacking a transformation zone, and findings related to HPV DNA tests.This code captures abnormal cellular changes detected through cytological examination of cervical specimens when a more specific diagnosis cannot be made.

Example 1: A patient undergoes a routine Pap smear, and the cytology report returns with R87.618, indicating abnormal cellular changes that are not specifically classified., A patient with a history of HPV infection has a follow-up Pap smear, and the results show R87.618, requiring further investigation to rule out precancerous or cancerous changes., A patient presents with abnormal vaginal bleeding. A Pap smear is performed, and the cytology report comes back as R87.618, indicating the need for additional diagnostic procedures.

Documentation should include details about the specimen collection, the cytology report findings, and the planned follow-up procedures. The reason for the Pap smear (e.g., routine screening, follow-up, or symptom-related) should also be documented.

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