Coding dx for suspicion for high-grade squamous intraepithelial lesion

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cgarciamck87@gmail.com

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Good morning. A patient recently had a vaginal biopsy under anesthesia done. She has a history of cervical cancer. Biopsy was done due to patient complaining of postmenopausal bleeding and a recent PAP showing the presence of high risk HPV.

We received the pathology report. When submitting the coding for this procedure, would R87.621 be more appropriate since it's not stating confirmed?
 
cgarciamck87@gmail.com said:
Good morning. A patient recently had a vaginal biopsy under anesthesia done. She has a history of cervical cancer. Biopsy was done due to patient complaining of postmenopausal bleeding and a recent PAP showing the presence of high risk HPV.

We received the pathology report. When submitting the coding for this procedure, would R87.621 be more appropriate since it's not stating confirmed?
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If the result is normal, you code for the reason the procedure was performed.
 
cgarciamck87@gmail.com said:
Result wasn't normal per pathology report. I'm sorry for not including further details. It says "scant fragment of squamous mucosa with atypia, suspicious for high-grade squamous intraepithelial lesion (VaIN 2-3).
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Cytology results involve examining a small sample of cells to identify abnormalities and if this had been a cytology smear result you would certainly report r87.621. But this was a biopsy result which involves analyzing a larger tissue sample to provide more detailed information about the presence and type of disease, such as cancer. Biopsies generally give you a better diagnosis than a cytology result. But this does not seem to be the case here. I would consult with your provider on assigning a diagnosis on whether the most appropriate diagnosis based on the biopsy result might be VAIN 1-2 (N89.1) or he/she thinks this statement qualifies to upcode to VAIN 3.
 
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