R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)

ICD10CM code

#### Name of the Condition
- High Grade Squamous Intraepithelial Lesion (HGSIL)
- Also referred to as Cervical Intraepithelial Neoplasia 2 or 3 (CIN 2/3)

#### Summary
High-grade squamous intraepithelial lesion (HGSIL) is a term used to describe precancerous changes in the cells on the surface of the cervix. Detected through a Pap smear, it is considered a precursor to cervical cancer if not treated.

#### Causes
- Human papillomavirus (HPV) infection, predominantly HPV types 16 and 18, is the primary cause of HGSIL.
- Persistent infection with high-risk HPV strains leads to cellular changes.

#### Risk Factors
- Early onset of sexual activity
- Multiple sexual partners 
- A weakened immune system (e.g., due to HIV/AIDS)
- Smoking
- Long-term use of oral contraceptives

#### Symptoms
- Often asymptomatic and found during routine Pap smear screening.
- In some cases, abnormal bleeding, unusual vaginal discharge, or pelvic pain might occur.

#### Diagnosis
- Detected through a Pap smear cytology showing abnormal cells.
- Follow-up with colposcopy and biopsy to confirm the diagnosis.

#### Treatment Options
- Loop electrosurgical excision procedure (LEEP) or cold knife conization to remove abnormal tissue.
- Cryotherapy for less extensive lesions.
- Regular monitoring with follow-up Pap smears and HPV testing post-treatment.

#### Prognosis and Follow-Up
- With appropriate treatment, the prognosis is generally good, reducing the risk of progression to cervical cancer.
- Routine follow-up is crucial to monitor for recurrence or persistence of the lesion.

#### Complications
- If untreated, HGSIL can progress to invasive cervical cancer.
- Possible fertility or pregnancy-related issues from treatment (e.g., cervical stenosis).

#### Lifestyle & Prevention
- Vaccination against HPV significantly reduces the risk.
- Routine Pap smears and HPV testing for early detection.
- Avoiding smoking can lower risk.

#### When to Seek Professional Help
- Abnormal bleeding or unexpected symptoms should prompt a medical consultation.
- Regular screenings as per medical guidelines.

#### Additional Resources
- [American Cancer Society](https://www.cancer.org)
- [Centers for Disease Control and Prevention (CDC)](https://www.cdc.gov/hpv/)
- [National Cervical Cancer Coalition](http://www.nccc-online.org)

#### Tips for Medical Coders
- Ensure accurate coding by confirming diagnosis with a pathology report.
- Be aware of documentation that may distinguish between HGSIL and other grades of intraepithelial lesions.

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