ICD-10 Coding for Cervical Intraepithelial Neoplasia Grade 1(N87.0, R87.610)
Complete ICD-10-CM coding and documentation guide for Cervical Intraepithelial Neoplasia Grade 1. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Intraepithelial Neoplasia Grade 1
N87-N87.9Primary Range
Dysplasia of cervix uteri
This range includes all grades of cervical dysplasia, with N87.0 specifically for CIN1.
Abnormal cytological findings in specimens from cervix uteri
Used for cytology findings without histological confirmation.
Encounter for gynecological examination
Used for routine gynecological exams 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 |
|---|---|---|---|
| N87.0 | Mild cervical dysplasia | Use when CIN1 is confirmed by biopsy. |
|
| R87.610 | ASC-US cytology without biopsy confirmation | Use for cytology findings without biopsy confirmation. |
|
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 CIN1
Essential facts and insights about Cervical Intraepithelial Neoplasia Grade 1
Primary ICD-10-CM Codes for cin1
Decision Criteria
clinical Criteria
- Biopsy confirms CIN1
Applicable To
- CIN1
- Mild dysplasia of cervix
Clinical Validation Requirements
- Biopsy report confirming CIN1
- Histopathology specifying mild dysplasia
Code-Specific Risks
- Incorrectly using for cytology findings without biopsy confirmation.
Coding Notes
- Ensure biopsy confirmation before using N87.0.
R87.610 - ASC-US cytology without biopsy confirmation
Use for cytology findings without biopsy confirmation.
Applicable To
- Atypical squamous cells of undetermined significance
Excludes
- Histologically confirmed CIN1 (N87.0)
Clinical Validation Requirements
- Pap smear showing ASC-US
Coding Notes
Do not use if biopsy confirms CIN1.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
ASC-US cytology without biopsy confirmation
R87.610Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Intraepithelial Neoplasia Grade 1 to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N87.0.
Impact
Clinical: May lead to inappropriate follow-up., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always specify the grade of dysplasia., Include biopsy results in documentation.
Impact
Reimbursement: May lead to incorrect billing and potential denials., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure biopsy confirmation before coding N87.0.
Impact
Using cytology codes for histologically confirmed cases.
Mitigation Strategy
Verify biopsy confirmation before coding.
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 Intraepithelial Neoplasia Grade 1, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Intraepithelial Neoplasia Grade 1
Use these documentation templates to ensure complete and accurate documentation for Cervical Intraepithelial Neoplasia Grade 1. These templates include all required elements for proper coding and billing.
Follow-up after abnormal Pap
Specialty: GynecologyRequired Elements
- Patient history
- Pap smear results
- Biopsy confirmation
- HPV status
- Follow-up plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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