Cytologic evidence of malignancy on smear of cervix
ICD-10 R87.614 is a billable code used to indicate a diagnosis of cytologic evidence of malignancy on smear of cervix.
Cytologic evidence of malignancy on smear of cervix refers to the identification of abnormal cells in a cervical smear (Pap test) that suggest the presence of cancerous or precancerous lesions. This finding is critical for early detection and management of cervical cancer, which is primarily caused by persistent infection with high-risk human papillomavirus (HPV). The cytological evaluation may reveal atypical squamous cells, squamous cell carcinoma, or adenocarcinoma, necessitating further diagnostic procedures such as colposcopy and biopsy. The significance of this finding lies in its potential to prompt timely intervention, thereby improving patient outcomes. It is essential for healthcare providers to document the context of the finding, including the patient's history, risk factors, and any previous abnormal results, to ensure comprehensive care and accurate coding.
Documentation must include the results of the Pap smear, any follow-up procedures, and the patient's risk factors for cervical cancer.
Routine screening in women aged 21-65, follow-up after abnormal Pap results.
Consideration of HPV vaccination status and previous cervical pathology.
Acute care documentation should detail the patient's presenting symptoms, the urgency of the findings, and any immediate interventions taken.
Patients presenting with abnormal vaginal bleeding or pelvic pain.
Rapid assessment and referral for gynecological evaluation may be necessary.
Used when performing a Pap smear that yields abnormal results.
Document the type of specimen collected and the results of the cytological examination.
Ensure that the procedure is linked to the diagnosis for accurate billing.
R87.614 indicates that cytologic evidence of malignancy has been found on a cervical smear, which is crucial for early detection and management of cervical cancer.
