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2025 ICD-10-CM code R87.622

Low-grade squamous intraepithelial lesion (LGSIL) on a vaginal cytologic smear.

Consult the official ICD-10-CM coding guidelines for proper use of this code.Ensure accurate classification and documentation to avoid coding errors.

Modifiers may be applicable depending on the circumstances of the procedure.Consult the appropriate guidelines for modifier application.

Medical necessity is established when abnormal vaginal cytology findings suggest a need for further evaluation to rule out or diagnose precancerous or cancerous conditions.

The clinical responsibility lies with the healthcare provider who performs the vaginal cytologic examination, assesses the results, and makes the diagnosis.This would typically be a gynecologist or pathologist.

IMPORTANT Related codes may include other R87.6x codes specifying different types of abnormal cervical or vaginal cytological findings, depending on the specific findings.Additionally, codes from other chapters might be necessary to describe related diagnoses or conditions.

In simple words: This code means that an abnormal cell growth was found in a sample taken from the vagina. This type of abnormal growth is considered precancerous and needs further investigation.

This ICD-10-CM code signifies the presence of a low-grade squamous intraepithelial lesion (LGSIL) detected during a cytological examination of a vaginal smear.LGSIL represents a precancerous condition characterized by abnormal cell growth in the vaginal lining.The diagnosis is established through microscopic analysis of the cellular sample obtained from the vagina. This code is for diagnostic purposes and should not be used for screening purposes unless specific criteria for diagnostic testing are met.

Example 1: A 35-year-old female presents with abnormal vaginal bleeding. A Pap smear is ordered and reveals LGSIL. Further evaluation, such as colposcopy and biopsy, is recommended., A 28-year-old female undergoes a routine Pap smear as part of a well-woman exam. The results reveal LGSIL, prompting additional diagnostic testing and potential intervention., A 42-year-old female presents with postmenopausal bleeding. A vaginal cytologic smear is performed revealing LGSIL.This requires a workup to rule out malignancy.

Complete patient history, including any symptoms (e.g., vaginal bleeding, discharge);detailed description of the cytological findings;results of any additional diagnostic procedures (e.g., colposcopy, biopsy); and the final diagnosis.

** This code should only be used when LGSIL is found on a vaginal smear.If the abnormal finding is in the cervix, the appropriate R87.61x code should be used.Always code to the highest level of specificity based on the complete clinical picture.

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