2025 ICD-10-CM code R87.619

Unspecified abnormal cytological findings in specimens from cervix uteri. This includes findings such as atypical glandular cells (AGC), atypical endocervical cells, or atypical endometrial cells on cytology.

Do not use this code if a more specific diagnosis is available. This code should be used as a placeholder until a definitive diagnosis is made. If the cytology shows features suggestive of a specific infection, the appropriate code for the infectious agent should be assigned.

Medical necessity for using this code is established when an abnormality is found in a cervical cytology sample but lacks specific diagnostic criteria for other, more definitive codes.Further investigation is usually medically necessary to determine the significance of the abnormal cells.

The clinician is responsible for evaluating the abnormal cytology results, correlating them with the patient's clinical picture, and determining the appropriate next steps for diagnosis and management. This may involve further investigations such as colposcopy, biopsy, or HPV testing.

IMPORTANT For more specific abnormalities, use specific codes such as those for Atypical Squamous Cells of Undetermined Significance (ASC-US) (R87.610), Atypical Squamous Cells, cannot exclude HSIL (ASC-H) (R87.611), Low-Grade Squamous Intraepithelial Lesion (LSIL) (R87.612), and High-Grade Squamous Intraepithelial Lesion (HSIL) (R87.613).

In simple words: The Pap smear from your cervix shows some abnormal cells, but we need more information to understand what they mean.This could be due to various reasons, and further tests may be required.

Unspecified abnormal cytological findings in specimens from cervix uteri. This is a non-specific code indicating an abnormality detected in a cervical cytology sample, but the specific nature of the abnormality is not further specified. It includes findings such as atypical glandular cells (AGC), atypical endocervical cells, or atypical endometrial cells on cytology.This code is used when more specific diagnoses like CIN or cancer are not confirmed.

Example 1: A 30-year-old female undergoes a routine Pap smear, and the cytology report returns with "atypical glandular cells, favor reactive."Since a specific diagnosis hasn't been established, R87.619 is used., A 45-year-old female has a Pap smear showing "atypical endocervical cells of undetermined significance."Colposcopy is scheduled for further evaluation, and R87.619 is used until a definitive diagnosis is reached., A 25-year-old female's Pap smear results show "atypical endometrial cells." Given the patient's age, this is considered an unexpected finding. The clinician uses R87.619 and recommends further evaluation with endometrial biopsy.

Documentation should include the cytology report detailing the abnormal findings. Any associated signs or symptoms, such as abnormal bleeding or discharge, should also be noted. The plan for further investigation and management should be clearly documented.

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