Unspecified abnormal cytological findings in specimens from anus
ICD-10 R85.619 is a billable code used to indicate a diagnosis of unspecified abnormal cytological findings in specimens from anus.
R85.619 is used to classify unspecified abnormal cytological findings in specimens obtained from the anus. This code is typically applied when cytological examinations, such as Pap smears or other cytological tests, reveal abnormal cells that do not fit into a more specific diagnosis. These findings may indicate a range of conditions, including infections, inflammatory processes, or neoplastic changes. Symptoms associated with abnormal findings may include rectal bleeding, discomfort, or changes in bowel habits, although many patients may be asymptomatic. The clinical context often involves screening for anal cancer or monitoring known lesions. The absence of specific findings necessitates the use of this unspecified code, which highlights the importance of thorough documentation to support the diagnosis and guide further management.
Detailed patient history, clinical findings, and rationale for cytological testing.
Routine screening for anal abnormalities, follow-up of previous abnormal findings.
Ensure that all relevant symptoms and previous medical history are documented to support the use of R85.619.
Acute presentation notes, including symptoms and any immediate interventions.
Patients presenting with rectal bleeding or pain requiring urgent evaluation.
Document any acute findings and the decision-making process for cytological testing.
Used when cytological testing is performed on anal specimens.
Document the type of specimen and findings.
Ensure alignment with the specialty performing the procedure.
R85.619 should be used when cytological findings from anal specimens are abnormal but do not fit into a more specific diagnosis. Comprehensive documentation is essential to support its use.
