Unspecified abnormal cytological findings in specimens from cervix uteri
ICD-10 R87.619 is a billable code used to indicate a diagnosis of unspecified abnormal cytological findings in specimens from cervix uteri.
R87.619 is used to classify unspecified abnormal cytological findings in specimens obtained from the cervix uteri. This code is often applied when cervical cytology tests, such as Pap smears, reveal atypical cells that do not fit into more specific categories of abnormal findings. These findings may indicate a range of conditions, from benign changes to potential precursors of cervical cancer. The lack of specificity in this code necessitates further investigation to determine the underlying cause of the abnormality. Common symptoms associated with abnormal cervical cytology may include abnormal vaginal bleeding, unusual discharge, or pelvic pain, although many patients may be asymptomatic. The diagnostic approach typically involves follow-up testing, such as HPV testing or colposcopy, to assess the nature of the abnormal cells and to rule out malignancy. Accurate coding is essential for appropriate patient management and treatment planning.
Documentation should include detailed patient history, results of cytological tests, and any follow-up procedures or referrals made.
Patients presenting for routine Pap smears with abnormal results requiring further evaluation.
Ensure that all follow-up actions are documented to support the use of R87.619.
Acute care documentation should include the reason for the visit, any acute symptoms, and results of any immediate tests performed.
Patients presenting with acute symptoms such as abnormal bleeding or pain who have a history of abnormal Pap results.
Emergency settings may require rapid assessment and documentation of findings to ensure appropriate coding.
Used when performing a Pap smear that results in abnormal findings.
Document the procedure performed, the findings, and any follow-up recommendations.
Ensure that the procedure is linked to the diagnosis of R87.619.
R87.619 should be used when there are abnormal cytological findings from cervical specimens that do not fit into more specific categories. It is essential to document the findings and any follow-up actions taken.
