Part B Insider (Multispecialty) Coding Alert

Question: If an abnormal pap smear prompted our clinician to undertake a cervical biopsy, how should we report the cervical biopsy as several diagnosis codes are available to report the dysplastic changes? Should I wait till the results of the biopsy are available to report it?

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Answer: You will not have to wait until you receive the results of the cervical biopsy to report the reason for the biopsy. You will instead base your diagnosis code on the abnormal pap smear results that made your clinician undertake the cervical biopsy. So, you will use the codes from the 795.0x series (Nonspecific abnormal papanicolaou smear of cervix) that correspond to the results of the abnormal pap smear.

Your selection of the fifth digit for this code depends on the nature of the abnormality involved. For instance, if the patient had an abnormal glandular Papanicolaou smear of the cervix, you would use 795.00. 

Other codes in the series reflect atypical squamous cells of undetermined significance (ASC-US) (795.01, Papanicolaou smear of cervix with atypical squamous cells of undetermined significance [ASC-US]) Papanicolaou smear of cervix with and atypical squamous cells that cannot exclude high grade squamous intraepithelial lesion (ASC-H) (795.02), through low-grade squamous intraepithelial lesions (LGSIL) (795.03,…with low-grade squamous intraepithelial lesion [LGSIL]), to high-grade squamous intraepithelial lesions (HGSIL) (795.04,…with high-grade squamous intraepithelial lesion [HGSIL]).

Finally, other codes in this series include:

• 795.05, Cervical high risk human papillomavirus [HPV] DNA test positive
• 795.06, Papanicolaou smear of cervix with ctyologic evidence of malignancy
• 795.07, Satisfactory cervical smear but lacking transformation zone
• 795.08, Unsatisfactory cervical cytology smear
• 795.09, Other abnormal papanicolaou smear of cervix and cervical HPV

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) (CIN I), and HGSIL correlates to either moderate (622.12, Moderate dysplasia of cervix) (CIN II) or severe (233.1, Carcinoma in situ of breast and genitourinary system; Cervix uteri) (CIN III) dysplasia on biopsy.

However, until the actual biopsy results are available you should not assign a diagnosis of dysplasia. 

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