Understanding a History of Abnormal Pap Smear diagnosis? This guide covers clinical documentation, medical coding (ICD-10 codes), and healthcare best practices for managing and documenting a history of abnormal cervical cytology, including ASCUS, LSIL, HSIL, AGC, and atypical glandular cells. Learn about follow-up procedures, diagnostic workup, and implications for patient care. Find information on Pap smear abnormalities, cervical dysplasia, and HPV testing related to a History of Abnormal Pap Test.
Also known as
Personal history of abnormal Pap
History of an abnormal Pap smear result.
Dysplasia of cervix uteri
Abnormal cell growth on the cervix, often found via Pap.
Carcinoma in situ of cervix uteri
Early-stage cervical cancer, detectable through Pap smears.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there any mention of cervical dysplasia or neoplasia?
When to use each related code
| Description |
|---|
| Abnormal Pap smear history |
| History of HPV infection |
| History of cervical dysplasia |
Coding Z87.4 (personal history of abnormal Pap) without specifying the abnormality type lacks detail for accurate risk adjustment and quality reporting.
Confusing active dysplasia (e.g., R87.619) with a history of abnormal Pap can lead to inaccurate coding and overstate current disease burden.
Documenting history of abnormal Pap without follow-up or resolution status (e.g., subsequent normal Pap or treatment) may hinder accurate clinical picture and coding.
Patient presents with a history of abnormal Pap smear, also documented as abnormal Papanicolaou test or cervical cytology. The patient reports (insert patient reported symptoms such as abnormal vaginal bleeding, pelvic pain, or no symptoms if asymptomatic). Past medical history includes (insert dates and specific findings of previous abnormal Pap smears including the specific abnormality e.g., ASCUS, LSIL, HSIL, AGC, AIS) and any subsequent colposcopy, biopsy, LEEP procedure, or other cervical interventions. Review of systems includes (relevant positive and negative findings related to gynecological health). On physical exam, (document pelvic exam findings including appearance of the cervix, presence or absence of lesions, and any tenderness). Assessment: History of abnormal Pap smear. Differential diagnoses include cervical dysplasia, cervical intraepithelial neoplasia (CIN), human papillomavirus (HPV) infection, and other cervical pathology. Plan: (Specify plan of care based on the specific history of abnormal Pap smears. This may include HPV testing, repeat Pap smear, colposcopy with or without biopsy, or referral to gynecology oncology depending on the severity and persistence of previous abnormalities). Patient education provided regarding the significance of abnormal Pap smears, the importance of follow-up care, and risk factors for cervical cancer. Medical coding considerations include ICD-10 code Z87.42 (personal history of abnormal Pap smear). The patient understands the plan and agrees to follow up as directed.