High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
ICD-10 R87.613 is a billable code used to indicate a diagnosis of high grade squamous intraepithelial lesion on cytologic smear of cervix (hgsil).
High grade squamous intraepithelial lesion (HGSIL) is a significant abnormal finding on a cervical cytologic smear, indicating the presence of precancerous changes in the squamous cells of the cervix. This diagnosis is typically derived from Pap smear results, where abnormal cells are identified that suggest a higher risk of progression to cervical cancer. HGSIL is often associated with persistent infection by high-risk human papillomavirus (HPV) types, particularly HPV 16 and 18. Patients may be asymptomatic, but some may present with abnormal vaginal bleeding, discharge, or pelvic pain. The identification of HGSIL necessitates further evaluation, often through colposcopy and biopsy, to assess the extent of the lesion and rule out invasive cancer. Early detection and management are crucial to prevent the progression to cervical cancer, making accurate coding essential for appropriate patient care and treatment planning.
Clear documentation of cytology results, follow-up plans, and any associated symptoms.
Routine screening results indicating HGSIL, management of patients with abnormal Pap smears.
Ensure that all relevant history, including HPV status and previous Pap results, is documented.
Documentation of acute presentations, including any symptoms such as bleeding or pain.
Patients presenting with acute symptoms related to cervical lesions.
Consider the urgency of follow-up and potential need for immediate intervention.
Used for routine screening and diagnosis of cervical lesions.
Document the indication for the Pap smear and any relevant patient history.
Ensure that the procedure is linked to the diagnosis of HGSIL.
HGSIL indicates a higher risk of progression to cervical cancer and requires careful monitoring and potential treatment.
