Low grade intrepith lesion cyto smr vagn (LGSIL)

This code indicates the presence of low-grade squamous intraepithelial lesions (LGSIL) identified on a cytologic smear obtained from the vagina. LGSIL represents mild cellular changes that may be precancerous, often associated with human papillomavirus (HPV) infection. It signifies abnormal cell growth that is less severe than high-grade lesions.

Use this code when a vaginal cytology report (e.g., Pap test) specifically documents a finding of LGSIL. This typically occurs during routine gynecological screening or follow-up for abnormal cervical or vaginal findings. Documentation must clearly state "low grade squamous intraepithelial lesion" and specify the vaginal origin.

• Do not use this code for LGSIL found on a cervical smear; use the appropriate R87.61x code for cervical findings.
• Ensure the documentation explicitly states "vagina" as the source of the abnormal cytology.
• This code is for the cytologic finding itself, not the underlying cause (e.g., HPV infection), which would be coded separately if confirmed.