ICD-10 Guide

R87.4

Abnormal immunological findings in specimens from female genital organs

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R87.4 is a billable code used to indicate a diagnosis of abnormal immunological findings in specimens from female genital organs.

Key Diagnostic Point:

R87.4 is used to classify abnormal immunological findings in specimens obtained from female genital organs. This code encompasses a range of immunological abnormalities that may be detected through laboratory testing of specimens such as cervical smears, vaginal swabs, or biopsies. Common findings may include the presence of atypical lymphocytes, abnormal antibody levels, or other immunological markers that suggest an underlying condition. These findings can indicate various pathologies, including infections, autoimmune disorders, or malignancies. The clinical significance of these findings often necessitates further investigation to determine the underlying cause and appropriate management. Accurate coding requires a thorough understanding of the clinical context and the specific immunological tests performed, as well as the implications of the findings for patient care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of potential underlying conditions that can lead to abnormal findings.
Need for precise documentation of laboratory results and clinical context.
Differentiation from other similar codes related to immunological findings.
Potential overlap with other diagnoses that may complicate coding.

Audit Risk Factors

Inadequate documentation of laboratory results.
Failure to specify the type of immunological abnormality.
Misinterpretation of abnormal findings leading to incorrect coding.
Lack of correlation between clinical findings and laboratory results.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation must include detailed laboratory results, clinical history, and any relevant symptoms or signs.

Common Clinical Scenarios

Patients presenting with abnormal Pap smears or unexplained vaginal discharge.

Billing Considerations

Consider the patient's overall health status and any concurrent conditions that may influence immunological findings.

Emergency Medicine

Documentation Requirements

Acute care documentation should include immediate lab results and any interventions performed.

Common Clinical Scenarios

Patients with acute pelvic pain or abnormal bleeding requiring urgent evaluation.

Billing Considerations

Rapid assessment and documentation of findings are crucial in emergency settings.

Coding Guidelines

Inclusion Criteria

Use R87.4 When

Follow official ICD
10 coding guidelines, ensuring that the code is used only when there is clear documentation of abnormal immunological findings from female genital specimens
Ensure that the findings are not classified elsewhere in the ICD
10 system

Exclusion Criteria

Do NOT use R87.4 When

No specific exclusions found.

Related CPT Codes

88141CPT Code

Cytopathology, cervical or vaginal (Pap smear)

Clinical Scenario

Used when a Pap smear shows abnormal findings requiring further immunological testing.

Documentation Requirements

Document the reason for the Pap smear and any follow-up tests performed.

Specialty Considerations

Ensure that the specialty performing the test is clearly documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of immunological findings, improving the accuracy of diagnoses and facilitating better patient management. R87.4 provides a clear classification for abnormal findings that were previously less defined in ICD-9.

ICD-9 vs ICD-10

Reimbursement & Billing Impact

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What types of findings are classified under R87.4?

R87.4 includes abnormal immunological findings such as atypical lymphocytes, abnormal antibody levels, and other immunological markers detected in specimens from female genital organs.

ICD-10 R87.4 is a billable code used to indicate a diagnosis of abnormal immunological findings in specimens from female genital organs.