Pathology/Lab Coding Alert

Question: Our pathologist reports the following diagnosis for a diagnostic cervical Pap smear: Low-grade squamous intraepithelial lesion (CIN I, mild dysplasia) with cellular changes. Which ICD-9 code(s) should we report -- 795.03 or 622.11 or both? Massachusetts Subscriber Answer: You should report 795.03 (Papanicolaou smear of cervix with low grade squamous intraepithelial lesion [LGSIL]). Your confusion stems from the fact that in addition to stating LGSIL, the pathologist lists CIN I and mild dysplasia in parenthesis. The pathologist might mention all of these terms because different classification systems exist for describing cervical cellular changes. For the type of changes your pathologist notes in this case, three distinct classification systems use different terminology as follows: • World Health Organization (WHO) -- Mild dysplasia • Cervical Intraepithelial Neoplasia (CIN) -- CIN I • Bethesda system -- Low-grade squamous intraepithelial lesions. CPT is different: Although all three above descriptions may be fairly equal from a clinical perspective, [...]