ICD-10 Coding for Abnormal Pap Smear(R87.610, R87.611)
Complete ICD-10-CM coding and documentation guide for Abnormal Pap Smear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Pap Smear
R87.610-R87.619Primary Range
Abnormal findings in specimens from female genital organs
This range includes specific codes for various abnormal Pap smear findings, such as ASC-US, ASC-H, LSIL, and HSIL.
Human papillomavirus (HPV) DNA test status
These codes are used to indicate HPV status, which is often tested alongside Pap smears.
Encounter for screening for malignant neoplasms of cervix
This code is used for screening encounters, often in conjunction with abnormal findings.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R87.610 | Atypical squamous cells of undetermined significance (ASC-US) | Use when Pap smear results indicate ASC-US. |
|
| R87.611 | Atypical squamous cells, cannot exclude HSIL (ASC-H) | Use when Pap smear results indicate ASC-H. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abnormal Pap smear
Essential facts and insights about Abnormal Pap Smear
Primary ICD-10-CM Codes for abnormal papanicolaou test smear
Decision Criteria
clinical Criteria
- Cytology report must specify ASC-US.
Applicable To
- ASC-US
Excludes
- Normal Pap smear
Clinical Validation Requirements
- Cytology report indicating ASC-US
- HPV test results if performed
Code-Specific Risks
- Misclassification if documentation is vague
Coding Notes
- Ensure documentation specifies 'ASC-US' explicitly.
R87.611 - Atypical squamous cells, cannot exclude HSIL (ASC-H)
Use when Pap smear results indicate ASC-H.
Applicable To
- ASC-H
Excludes
- Normal Pap smear
Clinical Validation Requirements
- Cytology report indicating ASC-H
- Colposcopy or biopsy results if performed
Coding Notes
Ensure documentation specifies 'ASC-H' explicitly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
HPV DNA test positive
R87.810Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Pap Smear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R87.610.
Impact
Clinical: May lead to inappropriate follow-up care., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to incorrect coding.
Mitigation Strategy
Use specific cytology terms in documentation., Ensure all findings are clearly stated.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation in patient records.
Mitigation Strategy
Use R87.615 + Z01.411 for diagnostic follow-up.
Impact
Using Z12.4 for diagnostic follow-ups can trigger audits.
Mitigation Strategy
Ensure correct differentiation between screening and diagnostic encounters.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abnormal Pap Smear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Pap Smear
Use these documentation templates to ensure complete and accurate documentation for Abnormal Pap Smear. These templates include all required elements for proper coding and billing.
Follow-up for abnormal Pap smear
Specialty: GynecologyRequired Elements
- Patient history
- Pap smear results
- HPV status
- Follow-up plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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