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R87.610
ICD-10-CM
ASCUS

Understanding ASCUS (Atypical Squamous Cells of Undetermined Significance) in healthcare? This resource provides information on ASC-US, Atypical Squamous Cells of Undetermined Significance diagnosis, clinical documentation, and related medical coding terms for accurate healthcare records. Learn about the significance of ASCUS Pap smear results and relevant medical terminology for effective communication in clinical settings.

Also known as

Atypical Squamous Cells of Undetermined Significance
ASC-US

Diagnosis Snapshot

Key Facts
  • Definition : Mildly abnormal cervical cells, changes may be HPV or precancerous.
  • Clinical Signs : Usually none, may have abnormal Pap smear.
  • Common Settings : Routine cervical cancer screening (Pap smear).

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R87.610 Coding
R87.61

Atypical squamous cells of undetermined significance

Abnormal cervical cells found during a Pap smear, uncertain if cancerous.

N87

Noninflammatory disorders of cervix uteri

Covers various non-cancerous cervical conditions, including dysplasia.

D06

In situ neoplasms of cervix uteri

Early-stage cervical cancer confined to the surface layer of cells.

Z12.89

Encounter for other screening for malignant neoplasms

Encompasses screening exams for various cancers, including cervical cancer.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is ASCUS or ASC-US documented?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Mildly abnormal squamous cells.
Low-grade squamous intraepithelial lesion.
High-grade squamous intraepithelial lesion.

Documentation Best Practices

Documentation Checklist
  • ASCUS Pap smear diagnosis documentation
  • Document Bethesda System classification
  • Specify squamous cell abnormality
  • Rule out high-grade lesions (e.g., HSIL)
  • Correlate with HPV test results
  • Consider colposcopy/biopsy indications

Coding and Audit Risks

Common Risks
  • Unspecified HPV Status

    ASCUS coding requires specifying HPV status (positive, negative, or not tested) for accurate reimbursement and clinical documentation.

  • Reflex HPV Testing

    If ASCUS is followed by reflex HPV testing, both ASCUS and the HPV test results must be documented and coded.

  • Management and Follow-up

    Accurate coding for ASCUS management (e.g., colposcopy, repeat Pap) is crucial for quality reporting and appropriate follow-up.

Mitigation Tips

Best Practices
  • HPV testing reflex or cotesting for ASCUS.
  • Document ASC-US with precise cell location.
  • Consider age and risk factors for ASCUS management.
  • Adhere to ASCCP guidelines for ASC-US follow-up.
  • Ensure proper ICD-10 coding for ASCUS diagnosis.

Clinical Decision Support

Checklist
  • Review patient history: HPV, smoking, prior Pap results.
  • Confirm adequate specimen cellularity for ASCUS diagnosis.
  • Reflex HPV testing if not already performed.
  • Document ASCUS interpretation, rationale, and plan.

Reimbursement and Quality Metrics

Impact Summary
  • ASCUS Pap smear reimbursement impacted by precise coding (87032 vs. 87149).
  • ASCUS diagnosis quality metrics: percentage of ASCUS requiring colposcopy, HPV testing.
  • Accurate ASCUS coding affects hospital reporting on cervical cancer screening rates.
  • Medical billing for ASCUS may vary based on subsequent management (HPV test, colposcopy).

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What is the recommended ASCUS Pap smear management protocol for a 25-year-old patient with a negative HPV test?

A: For a 25-year-old patient with an ASCUS Pap smear result and a negative HPV test, current guidelines recommend routine screening in 3 years. The negative HPV test significantly reduces the risk of underlying high-grade cervical intraepithelial neoplasia (CIN). This approach aligns with the American College of Obstetricians and Gynecologists (ACOG) recommendations, prioritizing a balance between thorough screening and minimizing unnecessary interventions. Explore how HPV testing improves the accuracy of ASCUS Pap smear management and reduces the need for immediate colposcopy.

Q: How do I distinguish between ASCUS and LSIL on Pap smear cytology, and what are the implications for patient management?

A: Distinguishing between ASCUS (Atypical Squamous Cells of Undetermined Significance) and LSIL (Low-Grade Squamous Intraepithelial Lesion) on Pap smear cytology can be challenging. ASCUS typically involves mild nuclear abnormalities, while LSIL shows more pronounced nuclear changes and a slightly increased nuclear-to-cytoplasmic ratio, suggestive of HPV infection. While both can indicate HPV infection, LSIL carries a higher likelihood of underlying CIN. Management diverges with ASCUS often warranting HPV testing or repeat cytology, whereas LSIL generally necessitates colposcopy for further evaluation. Consider implementing standardized cytology interpretation criteria within your practice to improve diagnostic accuracy and ensure consistent patient management. Learn more about the cytological features distinguishing ASCUS and LSIL.

Quick Tips

Practical Coding Tips
  • Code ASCUS as D50.9
  • Document ASC-US details
  • Check Bethesda guidelines
  • Review cell atypia specifics
  • Consider HPV testing codes

Documentation Templates

Patient presents for routine gynecological examination including cervical cancer screening with Pap smear.  The patient denies abnormal vaginal bleeding, discharge, or pelvic pain.  Past medical history is unremarkable for gynecologic abnormalities.  Family history is non-contributory.  Physical examination reveals a normal appearing cervix.  Pelvic examination is otherwise unremarkable.  Pap smear results returned as ASCUS, Atypical Squamous Cells of Undetermined Significance.  Differential diagnosis includes low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL).  Given the ASCUS Pap result, reflexive HPV testing was performed and results are pending.  Management will be determined based on HPV results and may include repeat Pap smear, colposcopy, or further diagnostic testing per current guidelines for ASCUS Pap smear management.  Patient education provided regarding the significance of ASCUS Pap smear results and the importance of follow-up care.  Patient expressed understanding of the plan.  ICD-10 code R87.619 used for abnormal Pap smear, unspecified.  CPT codes for the Pap smear and HPV testing will be billed accordingly depending on laboratory performed.  Follow-up appointment scheduled.