what is code for the abnormal pap smear with high grade squamous intraepithelial in icd-9-cm?

795.03 -- Papanicolaou smear of cervix with low- grade squamous intraepithelial lesion (LGSIL) 795.04 -- Papanicolaou smear of cervix with high- grade squamous intraepithelial lesion (HGSIL) (You would also use 795.04 for a report of cytologic evidence of carcinoma.) 795.05 -- Cervical high-risk human papillomavirus (HPV) DNA test positive

Full Answer

What is a high grade squamous intraepithelial lesion on cervical Pap smear?

High grade squamous intraepithelial lesion on cervical papanicolaou smear High grade squamous intraepithelial lesion, pap smear ICD-10-CM R87.613 is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 742 Uterine and adnexa procedures for non-malignancy with cc/mcc

What is a AIS lesion on a Pap smear?

AIS lesions may be referred to as precancer and may become cancer ( cervical adenocarcinoma) if not treated. Your health care provider will likely ask you to come back for a colposcopy . Cervical cancer cells ( squamous cell carcinoma or adenocarcinoma) are sometimes found on a Pap test.

What is the ICD 10 code for abnormal Pap smear?

Abnormal glandular pap smear of vagina; Atypical glandular cells on vaginal papanicolaou smear. ICD-10-CM Diagnosis Code R87.628. Other abnormal cytological findings on specimens from vagina. 2016 2017 2018 2019 2020 2021 Billable/Specific Code. ICD-10-CM Diagnosis Code R85.619 [convert to ICD-9-CM] Unspecified abnormal cytological findings in ...

What is an abnormal Pap smear result for HSIL?

Doru Paul, MD, is board-certified in internal medicine, medical oncology, and hematology. An abnormal Pap smear result of high-grade squamous intraepithelial lesion (HSIL) means that cells of the cervix (the narrow neck of a woman's uterus) look somewhat to very abnormal when examined under a microscope. 1

What is the ICD-10 code for HSIL?

R87.613ICD-10-CM Code for High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL) R87. 613.

What is ICD-10 code for low grade squamous intraepithelial lesion?

ICD-10 Code for Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)- R87. 612- Codify by AAPC.

What is an ICD 9 diagnosis code?

ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. The ICD-9 was used to code and classify mortality data from death certificates until 1999, when use of ICD-10 for mortality coding started.

What is the ICD-10 code for abnormal Pap smear?

ICD-10 Code for Unspecified abnormal cytological findings in specimens from cervix uteri- R87. 619- Codify by AAPC.

What is the ICD-10 code for history of abnormal Pap smear?

Unspecified abnormal cytological findings in specimens from cervix uteri. R87. 619 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

What is the difference between ICD-9 and ICD-9-CM?

The current ICD used in the United States, the ICD-9, is based on a version that was first discussed in 1975. The United States adapted the ICD-9 as the ICD-9-Clinical Modification or ICD-9-CM. The ICD-9-CM contains more than 15,000 codes for diseases and disorders. The ICD-9-CM is used by government agencies.

Which volumes of ICD-9-CM is used for diagnostic coding?

ICD-9-CM Volume 3 is a system of procedural codes used by health insurers to classify medical procedures for billing purposes. It is a subset of the International Statistical Classification of Diseases and Related Health Problems (ICD) 9-CM. Volumes 1 and 2 are used for diagnostic codes.

Are ICD-9 codes still used in 2021?

CMS will continue to maintain the ICD-9 code website with the posted files. These are the codes providers (physicians, hospitals, etc.) and suppliers must use when submitting claims to Medicare for payment.

What is abnormal Pap smear?

An abnormal Pap smear result of high-grade squamous intraepithelial lesion (HSIL) means that cells of the cervix (the narrow neck of a woman's uterus) look somewhat to very abnormal when examined under a microscope. 1 . Before cervical cancer forms, the cells of the cervix undergo abnormal changes called cervical dysplasia.

What does HSIL Pap smear mean?

An HSIL Pap smear result indicates that more defined changes in the size and shape of cervical cells have been detected, which indicates there is likely moderate-to-severe cervical dysplasia.

What is a colposcopy exam?

A colposcopy exam is an in-office procedure that allows a doctor to visually examine the cervix with a lighted instrument called a colposcope. 4  During the exam, the colposcope remains outside of the vagina. It acts like a microscope, allowing an in-depth view of the cervix.

What is the first step in colposcopy?

If the risk of CIN 3 is not very high, waiting for the results of biopsies done during a colposcopy is often the first step.

How often should you follow up on a Pap smear?

Your particular schedule of follow up will depend on results of any biopsies you had and treatments you have chosen, but is usually at least annually for a few years.

What is AIS in cervical biopsies?

Cervical biopsies can sometimes reveal adenocarcinoma in situ (AIS), which means there are abnormal glandular cells that have not spread beyond where they formed. AIS is sometimes referred to as stage 0 cancer. When AIS if found or cervical cancer is caught at an early stage, it's easier to treat and the survival rates are highest. 6 Treatments for AIS are often similar to those for severe dysplasia.

What is the purpose of a biopsy result?

A biopsy result obtained during a colposcopy allows a pathologist to see the actual changes in cells and their relation to each other within the tissue. This is needed to confirm whether or not precancerous changes or cancer are present.

What is a high grade squamous intraepithelial lesion?

High grade squamous intraepithelial lesion (HSIL) is a squamous cell abnormality associated with human papillomavirus (HPV). It encompasses the previously used terms of CIN2, CIN3, moderate and severe dysplasia and carcinoma in situ. This current terminology for HSIL was introduced by the Bethesda System for Reporting Cervical Cytology (TBS) for cytology specimens in 1988, and has since been adopted for histology specimens by the Lower Anogenital Squamous Terminology Standardization Consensus Conference (LAST) [1] and the World Health Organization (WHO) in 2012 and 2014, respectively.   Though not all HSIL will progress to cancer, it is considered a pre-cancerous lesion and therefore is usually treated aggressively.   Though HSIL can involve various cutaneous and mucosal sites within the anogenital tract, this summary will focus on cervical HSIL

What is the incidence risk of cervical intraepithelial neoplasia 3?

Incidence risk of cervical intraepithelial neoplasia 3 or more severe lesions is a function of human papillomavirus genotypes and severity of cytological and histological abnormalities in adult Japanese women.

What conditions can be mistaken for HSIL on biopsy?

Conditions that can be mistaken for HSIL on biopsy include early invasive carcinoma, atrophy, squamous metaplasia, transitional metaplasia and reactive atypia.

How old do you have to be to have a colposcopy?

For women ages 21-24, colposcopy is recommended following an HSIL cytology diagnosis.   Women over the age of 24 years old should also have colposcopy performed, though management with an excisional procedure is acceptable.  Around 60% of women with HSIL cytology will have at least CIN 2 on biopsy, with approximately 2% showing invasive cancer, though the latter is more likely in older women.   Women over 30 years of age have an 8% 5-year risk of cervical cancer after a diagnosis of HSIL.  Biopsies taken during colposcopy are examined by histology. [11]

How often should cervical carcinoma be screened?

Screening should be initiated at 21 years of age. Women ages 21 to 29 should be screened by cytology every three years. Women ages 30 to 65 should be screened with cytology and HPV co-testing every five years or by cytology alone every three years. Depending on the HPV test used, the test will provide pooled results for high-risk HPV subtypes and/or individual genotype results for HPV16 and 18.   The risk of HSIL in a patient with a positive HPV test and an abnormal pap test is approximately 20% and increases to 33% if HPV positive at more than one visit. [10]

What are the criteria for HSIL?

Histologic criteria for HSIL exceeds the extent and degree of nuclear atypia allowed for a diagnosis of LSIL and includes less maturation, a higher nuclear-to-cytoplasmic ratio, decreased organization from the lower immature cell layers to the superficial mature layers (loss of polarity), a greater degree of nuclear pleomorphism, highly irregular nuclear contours, increased mitotic index and abnormal mitotic figures, especially within more superficial layers of the epithelium. CIN3 must have full thickness atypia.   When faced with not-so-straight-forward biopsies where the pathologist is debating between benign mimics of HSIL, such as immature metaplasia or atypical atrophy, utilizing the biomarker p16 may help distinguish them, as p16 shows intense and continuous staining in HSILs and suggests infection with a high-risk HPV type.  [6][7]

How to diagnose HSIL?

Diagnosis of HSIL on cytology requires specific criteria to be met. The cells are smaller with less cytoplasmic maturity than that of LSIL.   Occasionally, the cytoplasm may be densely keratinized.   HSIL cells occur singly as well as in sheets or syncytial aggregates.   Though the size of the nucleus itself is variable, the cells must have a high nuclear-to-cytoplasmic ratio.   The nuclei are often hyperchromatic but can be normo- to hyperchromatic. The chromatin can range from evenly distributed and fine to coarsely granular. Nuclear contours must be distinctly irregular with prominent indentations and/or grooves. Nucleoli are usually not a feature of HSIL, though may be seen when HSIL involves the endocervical glands.

What does a Pap test show?

Pap test results show if cervical cells are normal or abnormal. A Pap test may also come back as unsatisfactory. Normal Pap test results: A normal test result may also be called a negative test result or negative for intraepithelial lesion or malignancy.

What is the purpose of a Pap cotest?

The HPV/Pap cotest uses a Pap test and HPV test together to check for both high-risk HPV and cervical cell changes.

What is HPV test?

The HPV test checks cells for infection with high-risk HPV types. The Pap test (also called a Pap smear or cervical cytology) collects cervical cells and looks at them for changes caused by HPV that may—if left untreated—turn into cervical cancer. It can also detect cervical cancer cells.

How long does it take for a cervical cancer screening to be done?

Both types of cervical cancer screening tests are usually done during a pelvic exam, which takes only a few minutes. During this exam, you lie on your back on an exam table, bend your knees, and put your feet into supports at the end of the table.

Can you have cervical cancer if you have abnormal Pap results?

An abnormal test result does not mean you have cervical cancer. Possible abnormal findings on a Pap test include ASC-US, AGC, LSIL, ASC-H, HSIL, AIS, or cervical cancer. Your health care provider will recommend follow-up steps you need to take based on your specific test result and your past test results.

What is the name of the medicine that pregnant women were exposed to before birth?

were exposed before birth to a medicine called diethylstilbestrol, (DES) which was prescribed to some pregnant women through the mid 1970s

Can HPV and Pap be done on the same sample?

When both an HPV test and a Pap test are done on the same sample, this is called HPV/Pap cotesting. A pelvic exam may include more than taking samples for an HPV and/or Pap test. Your health care provider may also check the size, shape, and position of the uterus and ovaries and feel for any lumps or cysts.

What is the code for endometrial hysteroscopy?

In the CPT® Index, look for Hysteroscopy/Ablation/Endometrial, guiding you to code 58563. The LGSIL is treated with cryocautery. In the CPT® Index, look for Cervix/Cauterization/Cryocautery referring you to code 57511. Verify the codes in the numeric section. Modifier 51 is appended to 57511 to show multiple procedures performed in the same session. In the ICD-10-CM Alphabetic Index look for Abnormal/Papanicolaou (smear)/cervix/low grade squamous intraepithelial lesion (LGSIL) guiding you to code R87.612. Verify in the Tabular List.

What is the code for nasal hemorrhage?

Rationale: Epistaxis is the term for nasal hemorrhage. In the CPT® Index look for Packing/Nasal Hemorrhage which directs you to code range 30901-30906. 30903 represents anterior packing for an uncontrolled or extensive nasal hemorrhage. Modifier 50 indicates this was done in both nares (bilaterally). In the ICD-10-CM Alphabetic Index look for Epistaxis referring you to code R04.0. Verification in the Tabular List confirms code selection.

What is the ICd 10 code for abdominal paracentesis?

Rationale: The patient is coming in for a subsequent (second or staged) abdominal paracentesis. In the CPT® Index look for Paracentesis/Abdomen directing you to 49082, 49083. Code 49083 includes imaging guidance so the radiology codes are not separately reported. 49083 does not have a post-operative period because it has 000 for the global days indicator. Modifier 58 is not required. Look in the ICD-10-CM Alphabetic Index for Cancer and you are directed to see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/ovary and select from the Malignant Primary (column) guiding you to code C56.-. In the Tabular List a 4 th character is reported to complete the code. Malignant ascites is found by looking for Ascites/malignant which directs you to code R18.0. In the Tabular List there is a code first note under code R18.0 indicated to "Code first malignancy, such as: malignant neoplasm of ovary (C56.-); secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6)." This means the malignant ascites is reported as a secondary code and the ovarian cancer is reported as the primary diagnosis code.

What is the ICd 10 code for poisoning?

Rationale: Over the counter medication taken in an improper dosage is considered a poisoning. ICD-10-CM guideline I.C.19.e.5.b states "When coding a poisoning or reaction to the improper use of a medication (for example: overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50." This was an accident (taken incorrectly). In the ICD10-CM Table of Drugs and Chemicals, look for Aspirin/Poisoning, Accidental (unintentional) column directing you to T39.011. In the Tabular List this code needs a 7 th character. The seventh character chosen is A. The first code to assign is the poisoning, T39.011A. The codes for the manifestations are assigned next and are found in the ICD-10-CM Alphabetic Index by looking for Tinnitus (ringing in the ear) H93.1-, 5 thcharacter 3 for both ears; Nausea/with vomiting (R11.2); and Drowsiness (R40.0). Verify code selection in the Tabular List.

What is the code for a cleft palate?

Rationale: In the CPT® Index, look for Palatoplasty 42145, 42200-42225. An alternate path is Cleft Palate/Repair which refers you to 42200-42225. Review of the code descriptions in the main section confirms code 42220 represents a secondary repair to a cleft palate. Modifier 53 is appended because the procedure was terminated after anesthesia due to extenuating circumstances. The diagnosis of a complete unilateral cleft palate is indexed in the ICD-10-CM Alphabetic Index under Cleft/palate referring you to code Q35.9. The unspecified code is the appropriate code because the surgeon did not provide specific information for the location of the cleft. Next, look for Seizure (s) (see also Convulsions) R56.9. Both listings direct the coder to R56.9 Unspecified convulsions. Code R56.9 is reported because the patient began to seize after administering the general anesthesia. Verify all code selections in the Tabular List.

What is the ICd 10 code for enlarged prostate?

RATIONALE: In the ICD-10-CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary symptoms (LUTS) and you are directed to N40.1. In the Tabular List there is an instructional note to Use additional code for associated symptoms, when specified. Urinary reten-tion is coded with R33.8.

What is the ICd 10 code for elevated blood pressure?

Rationale: ICD-10-CM guideline I.C.9.a.7 tells us to assign code R03.0 Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. To find the code using the ICD-10-CM Alphabetic Index look for Elevated, elevation/blood pressure/reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension which directs you to R03.0. The code is confirmed in the Tabular List.

What is cervical intraepithelial neoplasia?

The histological classification known as cervical intraepithelial neoplasia or CIN is a three-tier grading of CIN that corresponds to the number of layers of epithelial cells affected by atypia. [36][37] The CIN classification replaces the dysplasia terminology, with CIN 1, CIN 2, and CIN 3 being equivalent to mild dysplasia, moderate dysplasia, and severe dysplasia, respectively. The dysplasia descriptions are, however, no longer in use. There modified Bethesda system of cytological classification divides atypical squamous cells (ASC) into atypical squamous cells of undetermined significance (ASC-US), and atypical squamous cells-high-grade cannot be excluded (ASC-H). [38][39]

What are atypical squamous cells?

Atypical squamous cells that are related to an underlying SIL are associated with HPV infection. Following the initial acquisition of hrHPV, there is an inflammatory response that resolves after a short time. The chronic cases progress to more severe persistent infection associated with nuclear and cytoplasmic changes. In the presence of hrHPV 16 and 18, the viral genes E6 and E7 are thought to encode viral proteins in the infected squamous cells that promote the degradation of tumor suppressor gene proteins p53 and Rb respectively, resulting in malignant transformation. [26][47] Mahira Jahic and Elmir Jahic did a prospective analysis of 1,784 Pap smears and found that, out of 254 abnormal smears, overall, 74% persisted, 8% regressed, and 18% progressed to the worse stage.[46]  Studies using immunohistochemistry have associated the loss of certain capsid proteins in ASC-US specimens with progression to a more severe form of precancer. Eun Young Ki and colleagues showed that detection of HPV serotypes 16 and 18 in the absence of HPV L1 capsid expression predicted worsening of precancer.[48]  HIV positivity has also been known to promote HPV persistence and associated with a higher incidence of ASC-US. [25][49] Furthermore, a low CD4 count and not being on antiretroviral therapy were associated with the persistence of HPV infection. [50][49][31][51][46][47][12]

What is a negative cervical cytology?

Visual inspection of the ectocervix is the new way of screening, with immediate results and successful treatment of most of the identified precancerous lesions.[25]  Negative cervical cytology is reported as "negative for intraepithelial lesion or malignancy" (Negative/NILM).  Squamous cell abnormalities that can be detected by cervical cytology include ASC-US, atypical squamous cells-high-grade cannot be excluded (ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial session (HSIL), and invasive squamous cancer. Glandular cell abnormalities include atypical glandular cells (AGC), including endocervical and endometrial cells (not otherwise specified or favor neoplastic), endocervical adenocarcinoma in situ (AIS), and adenocarcinoma. This activity will improve the understanding of what ASC-US is and the implications and management of ASC-US diagnosis. [26][27][21][28]

What age do cervical lesions start?

Cervical precancer lesions are slow-growing and are commonest between the ages of 35 and 45 years but can be seen more frequently in HIV-positive women between the ages of 25 and 35. With the persistence of hrHPV infection over the years or decades, actual cancer peaks after the age of 50 years.[36]  We call ASC-US today originally described by Papanicolaou as atypical pathology, and it is a cytological nomenclature.[19]  The original laboratory technicians who worked on smears reported them simply as normal, atypical, or suspicious/malignant.[19]  ASC-US, therefore, represents a mix of squamous epithelial cells at different stages of transitioning from the lowest risk atypia to the worst form of precancer, with some harboring the potential to revert to normalcy. [32]

When to repeat HPV cytology?

In patients younger than 25 years with LSIL, ASC-US HPV-positive, or ASC-US without HPV testing, repeat cytology at 1 year is preferred, and if the result is NILM/ASC-US/LSIL, another repeat cytology is needed in 1 year, after that if the result is negative, then routine age-based screening is resumed. If HPV testing was first done for a patient with ASC-US, and the test was negative, there would be no need for the repeat cytology described above, and routine age-based screening could be directly resumed. Colposcopy is indicated if the first one-year repeat cytology shows HSIL/ASC-H/AGC/AIS, and also when the second one-year repeat cytology shows ASC-US or more severe lesions. [28]

How prevalent is HRHPV in ASC US?

Other studies have demonstrated a high prevalence of hrHPV in patients with ASC-US; one study in Brazil analyzed 1,340 liquid-based cytology specimens and found out that 64% of ASC-US specimens harbored hrHPV.[31]  In two separate studies, Mai Nishimura reported identifying hrHPV in 81 % of patients with ASC-US. In contrast, Ming Guo and colleagues reported a hrHPV 16/18 incidence rate of 37% in their ASC-US patient cohort, while one Mexican study found an incidence rate of 11.2 percent. [32][33][34] In another study in Turkey, 129 women with abnormal Pap smears were screened for hrHPV positivity, 94 had ASC-US diagnosis, and 94% of those had a hrHPV. [35]

Why is cervical cancer screening important?

Prioritizing and integrating cervical cancer screening in the daily management of women in primary healthcare facilities would go a long way to reducing new cases of cancer and possible elimination of deaths from invasive cervical cancer.

HSIL Pap Smear Results

Further Testing

Treatment

• When choosing the best treatment for a HSIL Pap smear result, healthcare providers look at the risk of CIN 3 being present. To do so, they look at your current tests, your history of cervical cancer screening, your past medical history, your age, and whether you plan to become pregnant in the future or are pregnant at the current time.

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