Part B Insider (Multispecialty) Coding Alert

Question: In a patient who had an abnormal Pap smear, a cervical biopsy was done. Is there a definitive code for the cervical biopsy? There are however, several diagnosis codes to report the dysplastic changes. Can we submit one of the dysplasia codes? Is it advisable to wait until the results of the biopsy?

Answer: You needn’t wait until you receive the results of the cervical biopsy to report the reason for the biopsy. 

For biopsy of the cervix, assuming that your physician did a colposcopy to obtain a biopsy specimen, you submit code 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix).

To assign the ICD-9-CM, look for a code for an abnormal Pap smear results that made your clinician undertake the cervical biopsy. So, you will use the codes from the 795.0x series (Abnormal Papanicolaou smear of cervix and cervical HPV) 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]) 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 cytologic 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 do not assign a diagnosis of dysplasia. 

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