Moderate cervical dysplasia

This code signifies the presence of moderately abnormal cell changes on the surface of the cervix, often detected during a Pap test. These dysplastic changes are more severe than mild dysplasia but do not yet indicate invasive cancer. It represents a precancerous condition requiring further monitoring or intervention.

Assign this code when documentation clearly states "moderate cervical dysplasia," "CIN II," or "cervical intraepithelial neoplasia grade 2." This diagnosis is typically made following a colposcopy and biopsy confirming the extent of the cellular abnormalities. It is appropriate for reporting the definitive diagnosis of moderate dysplasia.

• Do not use this code for mild (CIN I) or severe (CIN III) dysplasia; separate codes exist for those specific grades.
• Ensure the pathology report explicitly states "moderate" or "grade 2" to support this code.
• Sequence this code as the primary diagnosis when it is the reason for the encounter, such as for follow-up or treatment of the dysplasia.