Abnormal cytological findings in specimens from female genital organs
ICD-10 R87.6 is a billable code used to indicate a diagnosis of abnormal cytological findings in specimens from female genital organs.
R87.6 is used to classify abnormal cytological findings in specimens obtained from female genital organs, which may include the cervix, vagina, and uterus. These findings are typically identified through cytological examinations such as Pap smears or biopsies. Abnormal results may indicate various conditions, including infections, inflammatory processes, precancerous changes, or malignancies. Common cytological abnormalities include atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesions (LSIL), and high-grade squamous intraepithelial lesions (HSIL). The clinical significance of these findings necessitates further evaluation, which may include colposcopy, additional cytological testing, or histological examination. Accurate coding of R87.6 is crucial for appropriate patient management and treatment planning, as it reflects the need for further diagnostic procedures and potential interventions.
Documentation must include the reason for the cytological examination, results, and any follow-up plans.
Routine screening for cervical cancer, evaluation of abnormal bleeding, or follow-up of previous abnormal results.
Ensure that all abnormal findings are clearly documented and linked to the appropriate diagnosis.
Acute care documentation should include the patient's presenting symptoms, the urgency of the cytological examination, and any immediate interventions.
Patients presenting with acute pelvic pain or abnormal vaginal bleeding requiring urgent evaluation.
Consider the need for expedited follow-up on abnormal findings due to the potential for serious underlying conditions.
Used when performing a Pap smear that results in abnormal findings.
Documentation must include the indication for the Pap smear and the results.
Ensure that the procedure is linked to the diagnosis of abnormal findings.
Document the specific abnormal findings, the reason for the cytological examination, and any follow-up plans or treatments that are indicated based on the results.
