High grade squamous intraepithelial lesion on cytologic smear of anus (HGSIL)
ICD-10 R85.613 is a billable code used to indicate a diagnosis of high grade squamous intraepithelial lesion on cytologic smear of anus (hgsil).
High grade squamous intraepithelial lesion (HGSIL) on cytologic smear of the anus indicates the presence of abnormal squamous cells that have a high likelihood of progressing to anal cancer if left untreated. This finding is typically identified through a Pap smear or anal cytology, which is performed to screen for anal dysplasia, particularly in high-risk populations such as those with a history of human papillomavirus (HPV) infection, immunocompromised individuals, or those with a history of anal intercourse. Symptoms may include anal discomfort, bleeding, or changes in bowel habits, although many patients may be asymptomatic. The diagnosis of HGSIL necessitates further evaluation, often including a biopsy to confirm the presence of dysplastic cells and to rule out invasive carcinoma. Early detection and management are crucial to prevent progression to anal cancer, making awareness and screening in at-risk populations essential.
Documentation should include a detailed history of symptoms, risk factors, and results of cytologic examinations.
Patients presenting for routine screening or with symptoms such as anal bleeding or discomfort.
Consideration of patient history, including HPV status and immunocompromised conditions.
Acute care documentation must include a thorough assessment of symptoms and any immediate interventions performed.
Patients presenting with acute anal pain or bleeding requiring urgent evaluation.
Rapid assessment and potential referral for further evaluation or biopsy.
Used when performing a Pap smear that identifies HGSIL.
Document the type of specimen collected and the results of the cytology.
Ensure that the procedure is linked to the diagnosis of HGSIL.
HGSIL indicates a high risk of progression to anal cancer, necessitating close monitoring and potential intervention.
Patients at high risk, such as those with a history of HPV or immunocompromised status, should be screened annually or as recommended by their healthcare provider.
