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v1.0.0
ICD-10 Guide
ICD-10 CodesR87.9

R87.9

Unspecified abnormal finding in specimens from female genital organs

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R87.9 is a billable code used to indicate a diagnosis of unspecified abnormal finding in specimens from female genital organs.

Key Diagnostic Point:

R87.9 is used to classify unspecified abnormal findings in specimens obtained from female genital organs, which may include tissues, fluids, or other biological samples. This code is often applied when laboratory tests reveal abnormalities that do not fit into more specific categories. Common findings may include atypical cells, inflammation, or other nonspecific changes that warrant further investigation. The use of this code is essential in cases where the clinician has not yet determined the exact nature of the abnormality or when the findings are inconclusive. It is crucial for coders to ensure that the documentation supports the use of this code, as it reflects a need for further diagnostic evaluation or monitoring. Accurate coding is vital for appropriate patient management and for ensuring that healthcare providers receive proper reimbursement for their services.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality
  • Lack of specificity in clinical findings
  • Potential overlap with other codes
  • Need for additional diagnostic clarification

Audit Risk Factors

  • Inadequate documentation to support the unspecified nature of the finding
  • Failure to follow up on abnormal findings
  • Misinterpretation of lab results leading to incorrect coding
  • Inconsistent use of the code across different providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Documentation should include detailed descriptions of the findings, any relevant patient history, and plans for further evaluation.

Common Clinical Scenarios

Patients presenting with abnormal Pap smears or biopsy results that require further investigation.

Billing Considerations

Ensure that all findings are clearly documented and that any follow-up actions are noted.

Emergency Medicine

Documentation Requirements

Acute care documentation should include the reason for specimen collection, findings, and any immediate interventions.

Common Clinical Scenarios

Patients presenting with acute pelvic pain and abnormal lab results necessitating urgent evaluation.

Billing Considerations

Document the urgency of the findings and any immediate treatment provided.

Coding Guidelines

Inclusion Criteria

Use R87.9 When
  • According to ICD
  • CM guidelines, R87
  • 9 should be used when no more specific code is available to describe the abnormal finding
  • Coders must ensure that the documentation supports the use of this code and that it is not used inappropriately when a more specific diagnosis can be made

Exclusion Criteria

Do NOT use R87.9 When
No specific exclusions found.

Related CPT Codes

88141CPT Code

Cytopathology, cervical or vaginal (Pap smear)

Clinical Scenario

Used when a Pap smear is performed and results indicate abnormal findings.

Documentation Requirements

Documentation must include the reason for the Pap smear and the results.

Specialty Considerations

Ensure that the results are clearly linked to the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of abnormal findings, which can improve patient management and reimbursement accuracy. R87.9 serves as a catch-all for unspecified findings, emphasizing the need for thorough documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of abnormal findings, which can improve patient management and reimbursement accuracy. R87.9 serves as a catch-all for unspecified findings, emphasizing the need for thorough documentation.

Reimbursement & Billing Impact

reimbursement accuracy. R87.9 serves as a catch-all for unspecified findings, emphasizing the need for thorough documentation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R87.9?

Use R87.9 when there are abnormal findings in specimens from female genital organs that do not have a more specific diagnosis. Ensure that documentation supports the unspecified nature of the finding.