ICD-10 Guide

R87.616

Satisfactory cervical smear but lacking transformation zone

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R87.616 is a billable code used to indicate a diagnosis of satisfactory cervical smear but lacking transformation zone.

Key Diagnostic Point:

R87.616 refers to a cervical smear that has been deemed satisfactory for evaluation but does not include cells from the transformation zone, which is critical for assessing potential cervical pathology. The transformation zone is the area where the squamous and columnar epithelial cells meet, and it is where most cervical pre-cancerous changes occur. A satisfactory smear indicates that the sample was adequate for analysis, but the absence of the transformation zone raises concerns about the completeness of the sample. This situation may necessitate further investigation, such as a repeat Pap smear or colposcopy, to ensure that any potential abnormalities are not overlooked. The lack of transformation zone cells can occur due to various reasons, including improper sampling technique, anatomical variations, or the presence of cervical lesions that obscure the transformation zone. Clinicians must carefully evaluate the implications of this finding and consider the patient's history and risk factors for cervical cancer.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Understanding the significance of the transformation zone in cervical pathology.
Differentiating between satisfactory and unsatisfactory smears.
Recognizing the need for follow-up procedures based on the absence of transformation zone cells.
Navigating documentation requirements for repeat testing or additional procedures.

Audit Risk Factors

Inadequate documentation of the reason for the absence of transformation zone cells.
Failure to document follow-up actions taken after the finding.
Misinterpretation of the smear results leading to incorrect coding.
Not linking the diagnosis to appropriate follow-up procedures.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation should include the reason for the cervical smear, results, and any follow-up plans.

Common Clinical Scenarios

Routine screening in women, follow-up after abnormal results.

Billing Considerations

Consideration of patient history, including previous abnormal Pap results and HPV status.

Emergency Medicine

Documentation Requirements

Acute care documentation should detail the patient's presenting symptoms and the rationale for cervical evaluation.

Common Clinical Scenarios

Patients presenting with abnormal vaginal bleeding or pelvic pain.

Billing Considerations

Rapid assessment of potential cervical pathology in acute settings.

Coding Guidelines

Inclusion Criteria

Use R87.616 When

Follow the official ICD
CM coding guidelines, ensuring that the code is used only when the cervical smear is satisfactory but lacks transformation zone cells
Document the clinical rationale for the smear and any follow
up actions

Exclusion Criteria

Do NOT use R87.616 When

No specific exclusions found.

Related CPT Codes

88141CPT Code

Cytopathology, cervical or vaginal, screening

Clinical Scenario

Used when performing a Pap smear.

Documentation Requirements

Document the type of specimen collected and the results.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of R87.616.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cervical smear results, improving the accuracy of data collection and patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cervical smear results, improving the accuracy of data collection and patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of cervical smear results, improving the accuracy of data collection and patient management.

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 does R87.616 indicate?

R87.616 indicates a satisfactory cervical smear that lacks cells from the transformation zone, which may necessitate further evaluation.

When should I use R87.616?

Use R87.616 when a cervical smear is satisfactory but does not include transformation zone cells, and ensure appropriate follow-up is documented.

ICD-10 R87.616 is a billable code used to indicate a diagnosis of satisfactory cervical smear but lacking transformation zone.