Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)
ICD-10 R87.621 is a billable code used to indicate a diagnosis of atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (asc-h).
R87.621 refers to the presence of atypical squamous cells on a cytologic smear of the vagina that cannot definitively exclude the possibility of a high-grade squamous intraepithelial lesion (HSIL). This finding is significant as it indicates a potential precursor to cervical cancer, necessitating further evaluation. ASC-H is a category used in the Bethesda System for reporting cervical cytology results, highlighting the need for careful follow-up. Patients may present with no symptoms, or they may have abnormal vaginal bleeding, discharge, or discomfort. The abnormal cells are typically identified during routine Pap smears, and their presence warrants further diagnostic procedures such as colposcopy and biopsy to determine the presence of HSIL or invasive cancer. Accurate coding is crucial for appropriate patient management and treatment planning.
Documentation should include the results of the cytology report, any symptoms, and follow-up plans.
Routine screening in asymptomatic patients or evaluation of abnormal bleeding.
Ensure that all findings are clearly documented to support the diagnosis and any subsequent procedures.
Acute care documentation should include the patient's presenting symptoms, cytology findings, and any immediate interventions.
Patients presenting with acute vaginal bleeding or pain.
Emergency settings may require rapid assessment and documentation of findings to ensure appropriate follow-up.
Used when performing a Pap smear that results in ASC-H.
Document the type of specimen collected and the results of the cytology.
Ensure that the procedure is linked to the diagnosis of ASC-H.
ASC-H stands for atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion, indicating that further evaluation is necessary to rule out HSIL.
