Abnormal cytological findings in specimens from cervix uteri
ICD-10 R87.61 is a billable code used to indicate a diagnosis of abnormal cytological findings in specimens from cervix uteri.
R87.61 refers to abnormal cytological findings in specimens obtained from the cervix uteri, typically identified through Pap smears or cervical biopsies. These findings may indicate the presence of atypical squamous cells, glandular cells, or other cellular abnormalities that could suggest precancerous changes or malignancy. Common causes of abnormal cytological findings include human papillomavirus (HPV) infection, inflammation, and other benign conditions. The diagnostic approach often involves follow-up testing, such as HPV testing, colposcopy, and possibly biopsy to determine the nature of the abnormality. Accurate coding requires a thorough understanding of the clinical context, including the patient's history, the type of specimen collected, and the specific findings reported by the pathologist.
Complete patient history, including previous Pap results and HPV status.
Routine screening results showing abnormal findings.
Ensure follow-up plans are documented to support coding.
Acute care notes detailing the patient's presenting symptoms and any immediate interventions.
Patients presenting with abnormal bleeding or pelvic pain.
Document any urgent interventions or referrals made.
Used when performing a Pap smear with abnormal findings.
Document the type of specimen and findings.
Ensure that the procedure is linked to the diagnosis of abnormal cytological findings.
Documentation should include the type of cytological findings, any relevant patient history, follow-up plans, and results of any additional tests performed.
