2025 ICD-10-CM code R87.624
Cytologic evidence of malignancy on a vaginal smear.
Medical necessity for using this code is established by the presence of abnormal cells on the vaginal Pap smear suggesting malignancy, requiring further investigation to determine the cause and guide appropriate management.
It is the clinician's responsibility to interpret the results of the Pap smear and determine appropriate next steps, such as further investigation with colposcopy and/or biopsy. They must also thoroughly document the findings and recommendations in the patient's medical record.
In simple words: A Pap smear of your vagina showed abnormal cells that may be cancerous.
This code signifies the presence of abnormal cells indicative of malignancy found on a cytologic examination (Pap smear) of the vagina.
Example 1: A 35-year-old female presents for a routine gynecological exam. A Pap smear is performed, and the pathology report returns with a diagnosis of R87.624. A colposcopy is scheduled for further evaluation., A 50-year-old female with a history of abnormal Pap smears undergoes a routine Pap smear, which is coded as R87.624. A biopsy confirms the presence of vaginal cancer., During a routine check-up, a 25-year-old female's Pap smear results are coded as R87.624. After additional testing and a colposcopy, it is determined the abnormal cells are a result of a vaginal infection. The infection is treated, and a follow-up Pap smear is scheduled.
The medical record should include details of the Pap smear collection, the cytology report indicating the evidence of malignancy, and any planned follow-up procedures or treatments.
** It is important to note that this code (R87.624) indicates cytologic evidence of malignancy and does not definitively diagnose cancer. Further investigation is always necessary, and it's crucial to differentiate between cytological and histological findings.
- Specialties:Gynecology, Oncology, Pathology, Family Medicine
- Place of Service:"Office", "Hospital", "Outpatient Hospital", "Independent Clinic"