Find information on Papanicolaou test (Pap smear) diagnosis coding, including ICD-10 codes, SNOMED CT codes, and relevant medical terminology. Learn about proper clinical documentation for Pap smear results, abnormal Pap smear diagnosis, cervical cancer screening, and HPV testing. This resource provides guidance for healthcare professionals on accurate coding and documentation practices for Papanicolaou test results in electronic health records. Explore details on ASCUS, LSIL, HSIL, AGC, and other relevant cytology findings.
Also known as
Encounter for screening for cervical cancer
Routine Pap smear screening for cervical cancer.
Abnormal papanicolaou smear of cervix uteri
Abnormal Pap smear result indicating potential cervical issues.
Dysplasia of cervix uteri
Abnormal cell growth on the cervix, often detected by Pap smear.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the Pap test for screening?
Yes
Any abnormal findings?
No, diagnostic
Reason for diagnostic test?
When to use each related code
| Description |
|---|
| Normal pap smear |
| ASC-US (Atypical squamous cells) |
| LSIL (Low-grade squamous intraepithelial lesion) |
Coding Pap smears without specifying screening vs diagnostic leads to incorrect reimbursement and quality reporting.
Incorrectly coding HPV tests performed with a Pap can cause claim denials and compliance issues.
Imprecise coding of atypical cytology results (ASCUS, LSIL, etc.) impacts patient management and data accuracy.
Patient presents for routine cervical cancer screening with a Papanicolaou test (Pap smear, Pap test). Relevant medical history includes gravida 2, para 2, menarche at age 12, regular menses, and no prior history of abnormal Pap smears. Patient denies any current vaginal bleeding, discharge, or pelvic pain. She reports no history of sexually transmitted infections (STIs) and is currently in a monogamous relationship. A speculum examination revealed a normal cervix without lesions or abnormalities. A Pap smear specimen was collected and sent to the laboratory for cytological evaluation. Assessment: Routine cervical cancer screening. Plan: Patient will be notified of Pap smear results. If results are normal, routine screening will be continued per established guidelines. If results are abnormal, appropriate follow-up, including colposcopy, HPV testing, or biopsy, will be recommended and scheduled based on the specific cytological findings. Differential diagnoses include atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), atypical glandular cells (AGC), and squamous cell carcinoma. ICD-10 code Z12.31 (encounter for screening for malignant neoplasm of cervix) and CPT code 88141 (cervical or vaginal smear; conventional or liquid based) are applicable for this encounter. The patient was educated on the importance of regular Pap smears for early detection of cervical cancer and precancerous lesions. She verbalized understanding of the procedure and potential follow-up recommendations.