2025 ICD-10-CM code R87.69

Abnormal cytological findings in specimens from other female genital organs. This code excludes dysplasia of vulva (histologically confirmed) (N90.0-N90.3).

Code R87.69 should be used when there are abnormal cytological findings in specimens taken from the vulva, not including the cervix or vagina. More specific codes should be used if available (e.g., for abnormal findings on the cervix or vagina). Use additional codes to fully describe any associated symptoms (e.g., itching, pain).

Medical necessity for the cytology testing should be documented based on symptoms, risk factors, or routine screening guidelines.

The clinician is responsible for obtaining a proper specimen from the patient and having it analyzed.They must document the findings and any procedures performed. They are also responsible to inform the patient of the results and discuss with the patient any next steps for treatment/follow-up, including a referral to the appropriate specialist if needed.

In simple words: This code indicates abnormal cell findings from a Pap smear or other cytological test of the external female genitalia (vulva).

Abnormal cytological findings in specimens from other female genital organs.This includes abnormal findings in secretions and smears from the vulva.

Example 1: A patient presents for a routine gynecological exam. A Pap smear is performed, and the cytology report indicates atypical cells from the vulva. The provider schedules a biopsy to evaluate further., A 25-year-old female presents with vulvar itching and irritation.A culture and cytology are obtained. The culture is negative, but the cytology shows abnormal cells.R87.69 is used to reflect the abnormal cytological findings., A patient with a history of VIN (vulvar intraepithelial neoplasia) is seen for follow-up. A biopsy is taken, and the cytology shows abnormal cell changes.R87.69 is used until a definitive diagnosis is made.

Documentation should include details about the specimen collection, the location of the abnormality, the cytology report findings, and the planned follow-up or treatment.

** It is important to note that this code represents a finding, not a diagnosis. Further investigation, such as a biopsy or colposcopy, is usually required to determine the underlying cause of the abnormality.

  • Specialties:Obstetrics and Gynecology, Family Medicine, Women's Health
  • Place of Service:Office, Outpatient Hospital, Women's Health Clinic
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