Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)
ICD-10 R87.622 is a billable code used to indicate a diagnosis of low grade squamous intraepithelial lesion on cytologic smear of vagina (lgsil).
Low grade squamous intraepithelial lesion (LGSIL) refers to a mild abnormality in the squamous cells of the vagina, typically identified through a Pap smear. This finding indicates that the cells have undergone some changes, often due to human papillomavirus (HPV) infection, but are not yet cancerous. LGSIL is often associated with HPV types that are considered low-risk for progression to cervical cancer. Patients may be asymptomatic, but some may present with abnormal vaginal bleeding or discharge. The diagnosis is confirmed through cytological examination, and follow-up may include repeat Pap smears or colposcopy for further evaluation. It is crucial to monitor these lesions as they can resolve spontaneously or progress to higher-grade lesions if left untreated. Accurate coding of LGSIL is essential for appropriate management and follow-up care.
Documentation should include the results of the Pap smear, HPV status, and any symptoms the patient may be experiencing.
Routine screening in asymptomatic patients, follow-up of previous abnormal Pap results.
Consider the patient's age and history of cervical screenings when coding.
Acute care documentation should detail any presenting symptoms, such as abnormal bleeding or discharge.
Patients presenting with acute vaginal bleeding or discharge.
Emergency settings may require immediate assessment and documentation of any acute symptoms.
Used when performing a Pap smear that results in LGSIL.
Document the procedure performed and the findings.
Ensure that the procedure is linked to the diagnosis of LGSIL.
LGSIL indicates mild abnormalities that may resolve on their own but require monitoring to prevent progression to more severe lesions.
