2025 ICD-10-CM code R87.629
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs, and abnormal clinical and laboratory findings - Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Feed
Unspecified abnormal cytological findings in specimens from the vagina.
Medical necessity for coding R87.629 is established when an abnormal vaginal cytology result is obtained, and additional tests are needed to rule out or diagnose underlying conditions, such as infections or neoplasms.This code is essential for initiating further investigations to avoid potentially serious health issues.
The clinical responsibility for this code rests primarily with the gynecologist or other healthcare professional who performs the vaginal examination and interprets the cytology results.The physician's role includes ordering the appropriate tests, interpreting the results, and providing further diagnostic testing and treatment based on the findings.
- Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R87 (Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis)
In simple words: This code means that an abnormal result was found in a vaginal test. The test showed some unusual cells, but doctors don't know yet what caused this abnormality. More tests are needed to figure out what is going on.
This code signifies unspecified abnormal cytological findings detected during the examination of specimens obtained from the vagina.The abnormality is not further specified, meaning the exact nature of the cellular changes is undetermined. This could encompass various conditions, including but not limited to atypical cells, inflammatory changes, or other microscopic findings that deviate from normal vaginal cytology.Further investigation is typically required to determine the underlying cause.
Example 1: A 35-year-old female presents for a routine Pap smear. The cytology results reveal an unspecified abnormality. The physician orders further testing, including colposcopy and biopsy, to determine the cause of the abnormal cells.The code R87.629 is used to bill for the initial abnormal cytology finding., A 50-year-old female undergoes a vaginal examination as part of a routine checkup.An abnormal cytological finding is identified during microscopic analysis of the specimen. While further tests are planned,R87.629 is used for billing purposes until the precise nature of the abnormality is clarified., A 22-year-old female experiences vaginal discharge and discomfort.A vaginal swab is collected and sent for cytology. The results show unspecified abnormal cytology.The R87.629 code is utilized for billing until definitive diagnostic results are available, along with additional codes that may be needed to describe related symptoms.
Complete medical history, physical examination findings, detailed description of the abnormal cytological findings, results of any additional investigations (such as colposcopy, biopsy), and the physician's interpretation and diagnosis.
** This code should only be used when the specific type of abnormal cytological finding is not yet identified.It is a temporary code used for billing purposes until further investigation is completed. It's crucial to document the findings and the rationale for choosing this code in the patient's medical record.Always use the most specific code possible. If there is additional testing done that further specifies the findings, make sure to use the appropriate code to reflect this new information.
- Payment Status: Active
- Specialties:Gynecology, Obstetrics, Pathology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center