Low grade squamous intraepithelial lesion on cytologic smear of anus (LGSIL)
ICD-10 R85.612 is a billable code used to indicate a diagnosis of low grade squamous intraepithelial lesion on cytologic smear of anus (lgsil).
Low grade squamous intraepithelial lesion (LGSIL) on cytologic smear of the anus indicates the presence of abnormal squamous cells that are not cancerous but may indicate a precancerous condition. LGSIL is often associated with human papillomavirus (HPV) infection, which is a common sexually transmitted infection. The cytologic smear is a screening tool used to detect these abnormalities, and the findings suggest that while the lesions are low-grade, they warrant further evaluation and monitoring. Symptoms may include anal discomfort, bleeding, or changes in bowel habits, although many patients may be asymptomatic. The diagnosis is typically made through a combination of cytology and histological examination, with follow-up procedures such as colposcopy or biopsy often recommended to assess the extent of the lesions and rule out higher-grade lesions or malignancy.
Detailed documentation of cytology findings, patient history, and any follow-up procedures.
Routine screening in asymptomatic patients, follow-up of abnormal findings.
Ensure that HPV status is documented, as it may influence management and follow-up.
Acute care documentation including presenting symptoms and any immediate interventions.
Patients presenting with anal bleeding or discomfort.
Emergency settings may require rapid assessment and documentation of findings for appropriate coding.
Used when performing a liquid-based Pap smear for anal cytology.
Document the type of preparation and findings.
Ensure that the procedure aligns with the diagnosis for accurate billing.
LGSIL indicates the presence of low-grade squamous lesions that may require monitoring due to the potential for progression to higher-grade lesions or anal cancer.
