Unsatisfactory cytologic smear of cervix
ICD-10 R87.615 is a billable code used to indicate a diagnosis of unsatisfactory cytologic smear of cervix.
R87.615 refers to an unsatisfactory cytologic smear of the cervix, which indicates that the sample collected during a Pap test is inadequate for evaluation. This may occur due to insufficient cellular material, obscuring factors such as blood or inflammation, or technical issues during the collection or processing of the sample. An unsatisfactory result necessitates repeat testing to ensure that any potential cervical pathology, including dysplasia or malignancy, is not overlooked. The clinical significance of this finding lies in the need for follow-up to obtain a satisfactory sample, as well as the potential implications for the patient's cervical health. It is essential for healthcare providers to communicate the need for repeat testing to patients and to document the reasons for the unsatisfactory result thoroughly to ensure appropriate follow-up care.
Documentation should include the reason for the unsatisfactory smear, patient history, and any follow-up plans.
Patients presenting for routine Pap smears who receive unsatisfactory results.
Ensure that all relevant patient history and risk factors are documented to support the need for repeat testing.
Acute care documentation should include the context of the smear collection and any immediate follow-up actions.
Patients presenting with abnormal bleeding or other symptoms requiring urgent evaluation.
Consider the urgency of follow-up testing and ensure that documentation reflects the acute nature of the visit.
Used when a Pap smear is performed and results are unsatisfactory.
Documentation must include the reason for the smear and any follow-up plans.
Ensure that the procedure is linked to the diagnosis of unsatisfactory smear.
An unsatisfactory cytologic smear indicates that the sample collected during a Pap test is inadequate for evaluation, necessitating repeat testing to ensure proper cervical health assessment.
Documentation should include the reason for the unsatisfactory result, any relevant patient history, and a clear plan for follow-up testing.