ICD-10 Coding for Low Grade Squamous Intraepithelial Lesion(R87.612, R87.622)
Complete ICD-10-CM coding and documentation guide for Low Grade Squamous Intraepithelial Lesion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Low Grade Squamous Intraepithelial Lesion
R87.61-R87.62Primary Range
Abnormal findings on cytological and histological examination of female genital organs
This range includes codes for abnormal cytological findings on cervical and vaginal smears, specifically for LGSIL.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R87.612 | Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL) | Use when LGSIL is confirmed on a cervical cytology smear. |
|
| R87.622 | Low grade squamous intraepithelial lesion on cytologic smear of vagina | Use when LGSIL is confirmed on a vaginal cytology 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 LGSIL
Essential facts and insights about Low Grade Squamous Intraepithelial Lesion
Primary ICD-10-CM Codes for lgsil
Decision Criteria
clinical Criteria
- LGSIL confirmed on cervical cytology
Applicable To
- LGSIL on cervical smear
Excludes
- N87.0 Mild cervical dysplasia
Clinical Validation Requirements
- Cytology report confirming LGSIL
- HPV test results
- Colposcopy findings
Code-Specific Risks
- Excludes1 note with N87.0
Coding Notes
- Ensure documentation specifies lesion location and HPV status.
R87.622 - Low grade squamous intraepithelial lesion on cytologic smear of vagina
Use when LGSIL is confirmed on a vaginal cytology smear.
Applicable To
- LGSIL on vaginal smear
Clinical Validation Requirements
- Cytology report confirming LGSIL on vaginal smear
Coding Notes
Ensure documentation specifies lesion location.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
High risk HPV DNA test positive
R87.81Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Low Grade Squamous Intraepithelial Lesion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R87.612.
Impact
Clinical: Incomplete clinical picture., Regulatory: Potential audit trigger., Financial: Possible claim denial.
Mitigation Strategy
Always document HPV status when known.
Impact
Reimbursement: Denial of claims if coded together., Compliance: Violation of ICD-10 coding rules., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Avoid coding these together due to Excludes1 note.
Impact
Using R87.612 with N87.0 can trigger audits.
Mitigation Strategy
Educate coders on Excludes1 notes.
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 Low Grade Squamous Intraepithelial Lesion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Low Grade Squamous Intraepithelial Lesion
Use these documentation templates to ensure complete and accurate documentation for Low Grade Squamous Intraepithelial Lesion. These templates include all required elements for proper coding and billing.
Gynecology Progress Note
Specialty: GynecologyRequired Elements
- Patient history
- Cytology results
- HPV status
- Colposcopy findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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