Ob-Gyn Coding Alert

Question: Which ICD-9 code should I use when a finding of squamous cell metaplasia without dysplasia is the result of a colposcopy and biopsy of the cervix? The book says, -see condition.- 


California Subscriber

Answer: You should consider a finding of squamous cell metaplasia without dysplasia to be a normal finding.

It means that the cells of the cervix are repairing themselves and being replaced by new growth. This process is the body's normal method of healing irritation or inflamed cells. 

If you need this diagnosis so you can counsel the patient about the result, then use whatever diagnosis was known at the last visit or at the time of the colposcopy.

If this is a follow-up later (for, say, a repeat Pap smear), you can use V72.32 (Gynecological examination; encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear) if there was a previous normal Pap after the colposcopy or a history code V13.29 (Personal history of other diseases; other genital system and obstetric disorders; other genital system and obstetric disorders).