Unspecified abnormal cytological findings in specimens from vagina
ICD-10 R87.629 is a billable code used to indicate a diagnosis of unspecified abnormal cytological findings in specimens from vagina.
R87.629 is used to classify unspecified abnormal cytological findings in specimens obtained from the vagina. This code is typically applied when cytological 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, including infections, inflammatory processes, or precancerous changes. The lack of specificity in the findings necessitates further investigation to determine the underlying cause. Clinicians may order additional diagnostic tests, such as HPV testing or colposcopy, to clarify the nature of the abnormality. It is crucial for healthcare providers to document the clinical context and any associated symptoms, such as abnormal vaginal bleeding or discharge, to guide further management and ensure accurate coding.
Detailed documentation of patient history, symptoms, and any follow-up tests performed.
Routine screening Pap smears revealing abnormal results, follow-up on previous abnormal findings.
Ensure that all relevant clinical information is included to support the diagnosis and any subsequent procedures.
Acute care documentation must include the reason for the cytological test and any immediate findings.
Patients presenting with abnormal vaginal bleeding or discharge requiring urgent evaluation.
Rapid assessment and documentation are crucial, especially in acute settings where follow-up may be needed.
Used when performing a Pap smear that results in abnormal findings.
Documentation of the procedure performed and the results of the cytological analysis.
Ensure that the procedure is linked to the diagnosis of abnormal findings.
Document the clinical context, any symptoms the patient presents with, the results of the cytological test, and any follow-up actions or tests that are planned or performed.
