Other abnormal cytological findings on specimens from vagina
ICD-10 R87.628 is a billable code used to indicate a diagnosis of other abnormal cytological findings on specimens from vagina.
R87.628 is used to classify abnormal cytological findings from vaginal specimens that do not fall under more specific categories. These findings may include atypical squamous cells, abnormal glandular cells, or other cellular changes that suggest the presence of pathology but do not provide a definitive diagnosis. Common causes of these findings include infections (such as bacterial vaginosis or sexually transmitted infections), hormonal changes, or precancerous conditions. The diagnostic approach typically involves a thorough patient history, physical examination, and follow-up testing, such as colposcopy or biopsy, to determine the underlying cause of the abnormality. Accurate coding requires careful documentation of the findings and any subsequent diagnostic procedures performed.
Detailed patient history, physical examination findings, and results of any follow-up tests.
Routine gynecological exams revealing abnormal Pap smear results.
Ensure that all findings are clearly documented and linked to the patient's clinical presentation.
Acute care notes, including presenting symptoms and any immediate interventions.
Patients presenting with abnormal vaginal bleeding or discharge.
Document any acute findings and the rationale for further diagnostic testing.
Used when performing a Pap smear for screening purposes.
Document the type of specimen collected and the findings.
Ensure that the procedure is linked to the appropriate diagnosis.
Document the specific abnormal findings, any symptoms the patient presents with, and the rationale for any follow-up tests or procedures performed.
