Summary: Mild cervical dysplasia usually resolves on its own but should be monitored as it can progress to moderate or severe dysplasia, which, if not treated, could become cancerous.

Gynecologic diseases involve the female reproductive system and include benign and malignant tumors, pregnancy-related diseases, infection, and endocrine diseases. Cervical dysplasia or cervical intraepithelial neoplasia (CIN) is a common gynecological problem in which abnormal or precancerous cells develop in and around the cervix. The main cause of cervical dysplasia is the human papillomavirus virus (HPV) which spreads through sexual contact. According to the Centers for Disease Control and Prevention (CDC), HPV causes more than 9 out of 10 cervical cancers. 

Cervical dysplasia is not cancer. A diagnosis of cervical dysplasia indicates that there are abnormal cells on the surface of the cervix. Cervical Intraepithelial Neoplasia (CIN) can range from mild to severe, depending on the appearance of the abnormal cells. The three categories of CIN are:

Mild dysplasia usually resolves on its own but should be monitored as it can progress to moderate or severe dysplasia. If not treated, severe abnormalities could become cancerous.

Having HPV does not necessarily mean the person has cervical dysplasia. Experts believe that some high-risk strains of HPV and the duration of the infection may be the reason why some people develop cervical dysplasia after becoming infected with HPV, while others do not.

It can take 10 to 20 years, or even longer, for HPV-infected cervical cells to become cancerous. As HPV infection and cervical dysplasia don’t usually have symptoms, regular screening is important to monitor for cervical dysplasia and detect cervical cancer early. If abnormalities are detected in the cervical cells, further testing may be recommended.

If dysplasia has advanced to cervical cancer, it may cause symptoms such as abnormal menstrual bleeding, bleeding after menopause, increased vaginal discharge, back and pelvic pain, and pain during intercourse. 

All women who are or have been sexually active or are age 18 or older should have regular gynecological checkups. This is important to detect any abnormal changes to the cervix as early as possible. When diagnosed, detected early, and managed effectively, cervical cancer is considered one of the most successfully treatable types of cancer. The following tests are used to diagnose cervical dysplasia and determine the severity of the condition:

Severe cases of cervical dysplasia (CIN 1 or CIN 2) require treatment. There two general types of treatment for cervical dysplasia: 1) destruction (ablation) of the abnormal cells, and 2) removal (resection) of the abnormal area. The type of treatment option the physician chooses will depend on the severity of the cervical abnormality.

Cervical dysplasia rarely develops into cancer. But if it is not treated, there is a chance that the abnormal changes may become cervical cancer.

R87 is the ICD-10 code to report abnormal findings in specimens from female genital organs and includes abnormal findings in secretions and smears from cervix uteri, vagina, and vulva.  Specific codes include:

Total abdominal hysterectomy CPT codes include: 58150, 58152, 58180, 58200, 58210, and 58240.

Vaginal hysterectomy CPT codes include: 58260,58261, 58263, 58267, 58275, 58280, 58285, 58290, 58291, 58292, and 58294.

High-quality patient management requires meticulous documentation in the medical record. The results of consultations, examinations, and treatments must be recorded. This will also allow coders to assign the appropriate diagnosis/CPT code on claims for appropriate reimbursement.  

Globally, cervical cancer is the fourth most common cancer in women with an estimated 604,000 new cases in 2020. It is important to find abnormal cells through routine screenings and other measures so that they can be monitored or removed to help reduce the risk of cervical cancer. 

Adherence to routine cervical cancer screening guidelines is critical. Cervical cytology, primary HPV test, co-test, and Pap test are all effective screening options for detecting cervical precancerous lesions and cancer. The American College of Obstetricians and Gynecologists (ACOG), American Society of Colposcopy and Cervical Pathology (ASCCP), and Society of Gynecologic Oncology (SGO) recommend cervical cancer screening initiation at age 21 years. 

ACOG recommends three options for cervical cancer screening in individuals aged 30-65 years: primary HrHPV testing every 5 years, cervical cytology alone every 3 years, or co-testing with a combination of cytology and HrHPV testing every 5 years. 

However, despite the availability of these effective options, inadequate screening for cervical cancer continues to be a significant problem in the United States. A recent study that analyzed data on more than 20,000 women who were eligible for screening in the United States found that the rates of timely cervical cancer screening fell overall between 2005 and 2019. The study identified multiple barriers to screening, including women not being aware that screening is needed and not following up with their healthcare providers after abnormal findings from cervical screening. The researchers noted that the COVID-19 pandemic has likely worsened the situation. The study highlighted the importance of effective and efficient tools and systems to help clinicians stay up to date on screening guidelines and the need for more research on "the barriers that prevent clinicians from administering cervical cancer screening" (www.cancer.gov).  

The only way to prevent cervical dysplasia is to avoid getting HPV. Getting vaccinated is the best way to prevent HPV and cervical dysplasia. Although it cannot treat pre-existing HPV or cervical dysplasia, the vaccine may prevent infections from returning in some cases. People who already have an HPV infection can reduce their risk of it progressing into cervical cancer by getting regular Pap smears to diagnose cervical dysplasia. Practicing abstinence or safer sex and not smoking or using tobacco products are other ways to prevent HPV infections.

Natalie Tornese, CPC, is a Senior Group Manager responsible for Practice and Revenue Cycle Management at MOS. She brings 25 years of healthcare management experience to the company. Natalie has worked in varied leadership roles with practices and specialties. Her primary focus is revenue cycle management with an emphasis on Medical Billing, Coding, and Insurance Verification Management. She has written numerous articles on all aspects of Practice Management and presently manages a large team focused on Medical Billing, Medical Coding, Verification, and Authorization services for MOS. For more information on how MOS can help your practice, contact us at 1-800-670-2809 or visit us at www.outsourcestrategies.com.