ICD-10 Coding for History of Abnormal Pap Smear(R87.610, R87.615)
Complete ICD-10-CM coding and documentation guide for History of 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 History of Abnormal Pap Smear
R87.61-Primary Range
Abnormal findings in specimens from cervix uteri
This range includes codes for specific abnormal cytological findings such as ASC-US, LSIL, and unsatisfactory samples.
Encounter for screening for malignant neoplasm of cervix
Used for routine cervical cancer screening, especially in Medicare patients.
Encounter for gynecological examination (general) (routine) with abnormal findings
Used when a routine gynecological exam reveals 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 cytology report specifies ASC-US. |
|
| R87.615 | Unsatisfactory cytologic smear of cervix | Use when lab report indicates unsatisfactory cytologic smear. |
|
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 history of abnormal Pap smear
Essential facts and insights about History of Abnormal Pap Smear
Primary ICD-10-CM Codes for history abnormal papanicolaou test smear
Decision Criteria
clinical Criteria
- Cytology report confirms ASC-US
Applicable To
- ASC-US
Excludes
- Normal Pap smear
Clinical Validation Requirements
- Cytology report indicating ASC-US
- Bethesda classification
Code-Specific Risks
- Misclassification if not confirmed by cytology report.
Coding Notes
- Ensure cytology report is available to validate ASC-US.
R87.615 - Unsatisfactory cytologic smear of cervix
Use when lab report indicates unsatisfactory cytologic smear.
Applicable To
- Unsatisfactory sample
Excludes
- Satisfactory sample
Clinical Validation Requirements
- Lab report stating 'unsatisfactory specimen'
Coding Notes
Ensure documentation specifies unsatisfactory sample.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 History of 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: Leads to incorrect patient management., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Use specific terms like ASC-US or LSIL, Attach cytology reports
Impact
Reimbursement: Denial of claims if incorrect code is used., Compliance: Non-compliance with Medicare guidelines., Data Quality: Inaccurate data reporting for Medicare audits.
Mitigation Strategy
Use Z12.4 as primary code for Medicare patients.
Impact
Using R87.61- codes without specifying the sixth character.
Mitigation Strategy
Ensure documentation includes specific cytology findings.
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 History of Abnormal Pap Smear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Abnormal Pap Smear
Use these documentation templates to ensure complete and accurate documentation for History of Abnormal Pap Smear. These templates include all required elements for proper coding and billing.
Repeat Pap Smear after ASC-US
Specialty: OB/GYNRequired Elements
- Patient history
- Cytology results
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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