Atypical squamous cells of undetermined significance on cytologic smear of anus (ASC-US)
ICD-10 R85.610 is a billable code used to indicate a diagnosis of atypical squamous cells of undetermined significance on cytologic smear of anus (asc-us).
Atypical squamous cells of undetermined significance (ASC-US) on a cytologic smear of the anus indicate the presence of abnormal squamous cells that do not meet the criteria for a definitive diagnosis of malignancy or a specific benign condition. This finding is often encountered during routine screening procedures, such as anal Pap smears, which are performed to detect precancerous changes or anal cancer. ASC-US can arise from various causes, including inflammation, infection (such as HPV), or reactive changes due to trauma or irritation. The clinical significance of ASC-US is uncertain, necessitating further evaluation to rule out high-grade lesions or malignancy. Patients may be asymptomatic, or they may present with symptoms such as anal discomfort, bleeding, or changes in bowel habits. Follow-up typically involves repeat cytology, HPV testing, or biopsy to clarify the diagnosis and guide management.
Documentation should include the reason for the cytologic smear, patient history, and any symptoms present.
Routine screening in asymptomatic patients or evaluation of symptomatic patients with anal discomfort.
Consideration of risk factors such as HIV status, history of anal warts, or previous abnormal smears.
Acute care documentation should include presenting symptoms, any immediate interventions, and follow-up plans.
Patients presenting with anal bleeding or discomfort requiring urgent evaluation.
Rapid assessment of symptoms to rule out other acute conditions such as anal fissures or abscesses.
Used when performing a liquid-based cytology test for ASC-US.
Document the type of preparation and the results of the cytology.
Ensure that the procedure is linked to the diagnosis of ASC-US.
ASC-US stands for atypical squamous cells of undetermined significance, indicating abnormal cells that require further evaluation.
ASC-US is diagnosed through cytologic examination of anal smears, often during routine screening.
Follow-up may include repeat cytology, HPV testing, or biopsy to determine the significance of the findings.
