ICD-10 Coding for Abnormal Pap Test(R87.610, R87.612)
Complete ICD-10-CM coding and documentation guide for Abnormal Pap Test. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abnormal Pap Test
R87.61-Primary Range
Abnormal findings in specimens from cervix uteri
This range includes codes for specific cytological findings from Pap tests, such as ASC-US and LSIL.
Encounter for screening for malignant neoplasm of cervix
Used for routine cervical cancer screening encounters without 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 on cytologic smear of cervix (ASC-US) | Use when Pap test results indicate ASC-US. |
|
| R87.612 | Low grade squamous intraepithelial lesion on cytologic smear of cervix (LSIL) | Use when Pap test results indicate LSIL. |
|
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 test
Essential facts and insights about Abnormal Pap Test
Primary ICD-10-CM Codes for abnormal papanicolaou test
Decision Criteria
clinical Criteria
- Bethesda classification of ASC-US
documentation Criteria
- HPV test result documented
Applicable To
- ASC-US
Excludes
- High-grade squamous intraepithelial lesion (HSIL)
Clinical Validation Requirements
- Bethesda classification indicating ASC-US
- HPV test result (positive/negative)
Code-Specific Risks
- Failure to specify HPV status may lead to incomplete coding.
Coding Notes
- Ensure documentation specifies ASC-US and HPV status.
R87.612 - Low grade squamous intraepithelial lesion on cytologic smear of cervix (LSIL)
Use when Pap test results indicate LSIL.
Applicable To
- LSIL
Excludes
- High-grade squamous intraepithelial lesion (HSIL)
Clinical Validation Requirements
- Bethesda classification indicating LSIL
Coding Notes
Ensure documentation specifies LSIL.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Contact with and (suspected) exposure to human papillomavirus (HPV)
Z20.821Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Atypical squamous cells, cannot exclude HSIL (ASC-H)
R87.611Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abnormal Pap Test 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 for claim denials due to lack of specificity.
Mitigation Strategy
Use specific Bethesda terminology., Document HPV status clearly.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on cervical screening outcomes.
Mitigation Strategy
Use R87.61- codes for abnormal findings.
Impact
Using Z12.4 for abnormal findings instead of R87.61-.
Mitigation Strategy
Ensure coding reflects the actual findings of the Pap test.
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 Test, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abnormal Pap Test
Use these documentation templates to ensure complete and accurate documentation for Abnormal Pap Test. These templates include all required elements for proper coding and billing.
Abnormal Pap with ASC-US
Specialty: GynecologyRequired Elements
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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