Abnormal cytologic smear of anus
ICD-10 R85.61 is a billable code used to indicate a diagnosis of abnormal cytologic smear of anus.
An abnormal cytologic smear of the anus indicates the presence of atypical cells in the anal region, which may suggest underlying pathology such as dysplasia or malignancy. This finding is typically identified through a Pap smear or anal cytology test, which is performed to screen for anal cancer or precancerous conditions. Symptoms may include anal discomfort, bleeding, or changes in bowel habits, although many patients may be asymptomatic. The abnormal results necessitate further evaluation, including possible biopsy or additional imaging studies, to determine the underlying cause. Common causes of abnormal findings include human papillomavirus (HPV) infection, which is a significant risk factor for anal dysplasia and cancer. Other potential causes may include inflammatory conditions or previous history of anal lesions. The diagnostic approach often involves correlating cytological findings with clinical symptoms and history, as well as considering risk factors such as immunosuppression or history of anal intercourse. Accurate diagnosis and management are crucial to prevent progression to more severe conditions.
Detailed patient history, including risk factors and symptoms, must be documented. Follow-up plans and any referrals for further evaluation should also be noted.
Patients presenting with abnormal anal symptoms or routine screening in high-risk populations.
Consideration of comorbidities and immunosuppression status is essential for accurate coding.
Acute care documentation must include presenting symptoms, initial assessment findings, and any immediate interventions performed.
Patients presenting with acute anal pain or bleeding, requiring urgent evaluation.
Rapid assessment and documentation of findings are critical in emergency settings.
Used in conjunction with R85.61 when performing anal cytology screening.
Documentation of the specimen type and site, as well as the reason for the cytology test.
Ensure that the procedure is performed by qualified personnel and that results are communicated effectively.
An abnormal cytologic smear of the anus may indicate the presence of atypical cells, which could suggest dysplasia or malignancy, often related to HPV infection.
Documentation should include the patient's history, symptoms, the results of the cytology test, and any follow-up actions taken, such as referrals or additional testing.
