Moderate vaginal dysplasia

This code represents a precancerous condition of the vagina characterized by abnormal cell growth that is more severe than mild dysplasia but has not yet progressed to carcinoma in situ or invasive cancer. It indicates a significant degree of cellular atypia and architectural disorganization within the vaginal epithelium.

Use this code when the pathology report or physician documentation explicitly states "moderate vaginal dysplasia" or "vaginal intraepithelial neoplasia (VAIN) II." This diagnosis is typically made following a colposcopy with biopsy due to abnormal Papanicolaou (Pap) test results or visual inspection.

• Differentiate from mild (VAIN I) or severe (VAIN III) vaginal dysplasia; specific documentation of "moderate" is crucial.
• Do not use for cervical dysplasia; ensure the documentation clearly specifies the vagina as the affected site.
• Sequence as the primary diagnosis when the reason for the encounter is the management or follow-up of moderate vaginal dysplasia.