High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)
ICD-10 R87.623 is a billable code used to indicate a diagnosis of high grade squamous intraepithelial lesion on cytologic smear of vagina (hgsil).
High grade squamous intraepithelial lesion (HGSIL) on a cytologic smear of the vagina indicates the presence of abnormal squamous cells that have a high likelihood of progressing to cervical cancer if left untreated. HGSIL is typically identified through Pap smear testing, which screens for precancerous changes in cervical cells. Symptoms may not be present, as many women with HGSIL are asymptomatic. However, some may experience abnormal vaginal bleeding, unusual discharge, or pelvic pain. The diagnosis is confirmed through further evaluation, including colposcopy and biopsy. Common causes of HGSIL include persistent infection with high-risk human papillomavirus (HPV) types, particularly HPV 16 and 18. Early detection and treatment are crucial to prevent progression to invasive cancer. The management of HGSIL often involves excisional procedures such as loop electrosurgical excision procedure (LEEP) or cone biopsy to remove the affected tissue.
Complete history of present illness, including any symptoms, previous Pap results, and HPV status.
Routine screening in asymptomatic women, follow-up of abnormal Pap results.
Ensure documentation reflects the need for further diagnostic procedures and patient education regarding HGSIL.
Acute care notes should include presenting symptoms, any acute complications, and immediate management steps.
Patients presenting with abnormal bleeding or pain related to HGSIL.
Document any urgent interventions and ensure follow-up care is addressed.
Used during routine Pap smear screenings.
Document the type of specimen collected and the method of preparation.
Ensure that the cytology report is available for accurate coding.
HGSIL indicates a high risk of progression to cervical cancer, necessitating close monitoring and potential treatment.
