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Posted By Cathy on 01-31-2019, 13:16:22 in Ob-Gyn
Our doctor did a Colpo on a patient due to LGSIL result on her Pap. The path report from the Colpo, cervix, 12:00 biopsy states: squamous atypia, suspicious for metaplastic dysplasia, identified in a background of severe acute and chronic inflammation (see Comment)
Comment: The atypia present within the 12:00 biopsy is suspicious for metaplastic dysplasia, with areas raising concern for high grade squamous intraepithelial lesion (HSIL/CIN II). The suspicion heightened by the finding of focal block reactivity for high grade HPV

Do I use the LGSIL for the Colpo diagnosis, or would I change it to R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix. I question that since this isn't a smear, it was a biopsy. Thank you!
Comments (1)
Posted By Melanie Witt on 02-01-2019, 19:10:43
No, you may not report the R code since this was a biopsy rather than a smear. I think I would go with a Dx of CINII (N87.1) in this case, but you can check with the provider to be sure. The ICD10 rule is that the R codes can only be assigned when there is no histologic confirmation which is not the case here. Alternatively your provider may decide to assign a code for cervical dysplasia, unspecified (N87.9).
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