High grade intrepith lesion cyto smr vagn (HGSIL)

This code signifies the presence of high-grade squamous intraepithelial lesions (HGSIL) detected on a vaginal cytology smear, indicating significant cellular changes that are precancerous. HGSIL represents a severe dysplasia of the vaginal squamous epithelium, carrying a higher risk of progression to invasive carcinoma if left untreated.

Use this code when a pathology report from a vaginal smear (e.g., Pap test) specifically identifies HGSIL. This diagnosis typically prompts further investigation, such as colposcopy and biopsy, to confirm the extent and severity of the lesion. Documentation must clearly state "high-grade squamous intraepithelial lesion" and specify the specimen source as vaginal.

• Do not use this code for HGSIL found on cervical smears; a different code exists for cervical findings.
• This code represents a cytologic finding, not a histologic diagnosis. If a biopsy confirms a specific grade of dysplasia (e.g., VAIN 2, VAIN 3), a more specific histologic code should be used.
• Sequence this code as the primary diagnosis when the HGSIL is the reason for the encounter, such as for follow-up or treatment planning.