Ob-Gyn Coding Alert

Make the distinction between pre- and post Oct. 1 claims.

If a patient has cervical dysplasia, this means that she has abnormal cell growth on the surface of the cervix, which either indicates precancerous or cancerous cells. Based on this growth, a provider will classify these cells as being either low-grade (meaning it typically resolves on its own) or high-grade (which can lead to cancer).

ICD-9-CM: If you’re submitting a claim for an encounter that occurred prior to October 1, then you should submit one of the following codes:

• 622.10, Dysplasia of cervix, unspecified
• 622.11, Mild dysplasia of cervix
• 622.12, Moderate dysplasia of cervix.

ICD-10-CM: For claims occurring after October 1, 2015, then you should report:

• N87.0, Mild cervical dysplasia
• N87.1, Moderate cervical dysplasia
• N87.9, Dysplasia of cervix uteri, unspecified.

ICD-10-CM Change: You have a one-to-one relationship with these codes. ICD-10-CM differs in that these codes are among their own category (N87-) whereas ICD-9-CM includes these codes underneath the category “Noninflammatory disorders of cervix” (622-) with various other conditions, such as old laceration of cervix and leukoplakia of cervix.

Documentation: If your provider documents “Cervical intraepithelial neoplasia I [CIN I],” you should report N87.0.

If your provider documents “Cervical intraepithelial neoplasia II [CIN II],” you should report N87.1.

If your provider documents “anaplasia of cervix,” “cervical atypism,” or cervical dysplasia NOS, then you should report N87.9.

Here’s how you will find these codes in the Alphabetic Index:

Anaplasia cervix (see also Dysplasia, cervix) N87.9

Atypical, atypism —see also condition

- cervical N87.9

Dysplasia —see also Anomaly

- cervix (uteri) N87.9

- - mild N87.0

- - moderate N87.1

Neoplasia

- intraepithelial (histologically confirmed)

- - cervix (uteri) (CIN) (histologically confirmed) N87.9

- - - grade I N87.0

- - - grade II N87.1

Coder tips: You will find an Excludes1 note underneath the N87- category, forbidding you from reporting any of these codes with abnormal results from cervical cytologic examination without histologic confirmation (R87.61-), carcinoma in situ of cervix uteri (D06-), cervical intraepithelial neoplasia III (CIN III) (D06-), HGSIL of cervix (R87.613), and severe dysplasia of cervix uteri (D06-). Remember that a Pap smear result of HGSIL or LGSIL cannot be coded as dysplasia as this diagnosis depends on a biopsy confirmation.