Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
ICD-10 R87.612 is a billable code used to indicate a diagnosis of low grade squamous intraepithelial lesion on cytologic smear of cervix (lgsil).
Low grade squamous intraepithelial lesion (LGSIL) is a term used to describe abnormal changes in the squamous cells of the cervix, typically identified through a Pap smear or cervical cytology. These changes are often associated with human papillomavirus (HPV) infection, particularly with low-risk HPV types. LGSIL is considered a mild form of dysplasia, indicating that the cells are abnormal but not yet cancerous. Clinically, patients may not exhibit any symptoms, which is why routine screening is crucial. If symptoms do occur, they may include abnormal vaginal bleeding, unusual discharge, or pelvic pain. The diagnosis of LGSIL is significant as it necessitates further evaluation, often through colposcopy and biopsy, to rule out more severe lesions or cervical cancer. Management typically involves monitoring, as many LGSIL cases resolve spontaneously, but follow-up is essential to ensure that any progression is detected early.
Documentation must include the results of the Pap smear, any follow-up procedures, and patient education regarding the findings.
Routine screening in asymptomatic women, follow-up after abnormal Pap results.
Ensure that the patient's history includes HPV vaccination status and any previous cervical abnormalities.
Acute care documentation should include presenting symptoms, results of any immediate tests, and referrals for follow-up care.
Patients presenting with abnormal bleeding or discharge.
Consider the urgency of follow-up care and ensure proper referrals are documented.
Used when performing a Pap smear that results in LGSIL.
Document the collection method and any relevant patient history.
Ensure that the procedure is linked to the diagnosis of LGSIL.
LGSIL indicates mild dysplastic changes in cervical cells, often associated with HPV infection. It requires monitoring and potential follow-up to ensure no progression to more severe lesions.
