ICD-10 Coding for Cervical Dysplasia(N87.0, N87.1, R87.612, R87.613)
Complete ICD-10-CM coding and documentation guide for Cervical Dysplasia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Dysplasia
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N87.0 | Mild cervical dysplasia | Use when biopsy confirms CIN1. |
|
| N87.1 | Moderate cervical dysplasia | Use when biopsy confirms CIN2. |
|
| R87.612 | Low-grade squamous intraepithelial lesion on cytology | Use for cytology findings without biopsy. |
|
| R87.613 | High-grade squamous intraepithelial lesion on cytology | Use for cytology findings without biopsy. |
|
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 cervical dysplasia
Essential facts and insights about Cervical Dysplasia
Primary ICD-10-CM Codes for cervical dysplasia
Decision Criteria
clinical Criteria
- Biopsy confirms CIN1
Applicable To
- CIN1
Excludes
Clinical Validation Requirements
- Biopsy report stating 'CIN1' or 'mild dysplasia'
Code-Specific Risks
- Confusion with cytology-only findings.
Coding Notes
- Ensure biopsy confirmation before using.
N87.1 - Moderate cervical dysplasia
Use when biopsy confirms CIN2.
Applicable To
- CIN2
Excludes
- R87.613
Clinical Validation Requirements
- Biopsy showing 'CIN2' or 'moderate dysplasia'
Coding Notes
Biopsy confirmation is mandatory.
R87.612 - Low-grade squamous intraepithelial lesion on cytology
Use for cytology findings without biopsy.
Excludes
- N87.0
Clinical Validation Requirements
- Pap smear showing LSIL
Coding Notes
Do not use if biopsy confirms dysplasia.
R87.613 - High-grade squamous intraepithelial lesion on cytology
Use for cytology findings without biopsy.
Excludes
- N87.1
Clinical Validation Requirements
- Pap smear showing HSIL
Coding Notes
Do not use if biopsy confirms dysplasia.
Differential 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 Cervical Dysplasia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N87.0.
Impact
Clinical: Misrepresentation of disease severity., Regulatory: Potential audit failures., Financial: Incorrect billing and reimbursement.
Mitigation Strategy
Verify biopsy results before coding., Educate staff on coding guidelines.
Impact
Reimbursement: Incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data.
Mitigation Strategy
Use R87.612 instead.
Impact
Risk of coding cytology findings as histology-confirmed dysplasia.
Mitigation Strategy
Implement double-check system for biopsy confirmation.
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 Cervical Dysplasia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Dysplasia
Use these documentation templates to ensure complete and accurate documentation for Cervical Dysplasia. These templates include all required elements for proper coding and billing.
Post-Colposcopy Documentation
Specialty: GynecologyRequired Elements
- Colposcopy findings
- Biopsy results
- HPV status
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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