Ob-Gyn Coding Alert

Question: I know that new diagnosis codes are in effect as of Oct. 1, 2004. What is the difference between using 795.03 instead of 622.11, and 795.04 instead of 622.12?

Alabama Subscriber

Answer: Many coders find the classifications of cervical dysplasia and abnormal Pap results confusing. Pap smears, which are a screening tool, are graded from atypical squamous cells of undetermined significance (ASC-US), through low-grade squamous intraepithelial lesions (LGSIL) (795.03, Papanicolaou smear of cervix with low-grade squamous intraepithelial lesion [LGSIL]) to high-grade squamous intraepithelial lesions (HGSIL) (795.04, Papanicolaou smear of cervix with high-grade squamous intraepithelial lesion [HGSIL]).

But actual biopsies (rather than Pap smears) are classified as mild, moderate and severe cervical dysplasia or cervical intraepithelial neoplasia (CIN). Usually LGSIL on a Pap smear corresponds to mild dysplasia (622.11, Mild dysplasia of cervix), and HGSIL correlates to either moderate or severe dysplasia (622.12, Moderate dysplasia of cervix) on biopsy.

Therefore, you would not assign a diagnosis of dysplasia unless this finding was determined by a tissue biopsy.