Cervical Cytology - Clinical Terms for Smear Results

It is very important to be consistent with clinical terms when entering cervical cytology results. This ensure that smear searches result in accurate and complete reports.

There are many possible ways of coding results and recalls, and you should spend some time deciding on a possible coding methodology. Once a method has been decided, it may be advisable to produce a protocol to ensure that the appropriate codes are used at all times.

Note - Only the 4K2.., 4KA.. and 685.. hierarchies are available for coding cervical cytology results - the other hierarchies can be used on recording general history or recall entries:

The following smear codes can be selected from the Cytology - Add screen:

  • 4K2.. Cervical Smear result

  • 4K2.. 11 Dyskaryosis on cervical smear

  • 4K2.. 12 Dysplasia (dysk.) on cerv. smear

  • 4K22. Cervical smear: negative

  • 4K22.11 Smear NAD: no endocervic cells

  • 4K23. Cerv.smear: mild dyskaryosis

  • 4K23.11 CIN I - mild dyskaryosis

  • 4K24. Cerv.smear: severe dyskaryosis

  • 4K24.11 CIN III - severe dyskaryosis

  • 4K25 Cerv.smear:severe dysk.?inv.ca

  • 4K26. Cervical smear: ?gland neopl.

  • 4K27. Cervical smear: atrophic change

  • 4K27.11 Atrophic change on cerv. smear

  • 4K28. Cerv. smear: mod. dyskaryosis

  • 4k28.11 CIN II - moderate dyskaryosis

  • 4K29. Cerv. smear: borderline changes

  • 4K2A Cervical smear endocervical cells present

  • 4K2B Cervical smear endocervical cells absent

  • 4K2J. Cervical smear - low grade dyskaryosis

  • 4K2K. Cervical smear - high grade dyskaryosis (moderate)

  • 4K2L. Cervical smear - high grade dyskaryosis (severe)

  • 4K2M. Cervical smear - high grade dyskaryosis with features of invasive squamous carcinoma

  • 4K2N. Cervical smear - features of endocervical type glandular neoplasia

  • 4K2P. Cervical smear - features of non-cervical type glandular neoplasia

  • 4K290 Cervical smear - borderline change in squamous cells

  • 4K291 Cervical smear - borderline change in endocervical cells

  • 4K2Z. Cervical smear result NOS

  • 4K2Z.11 Nuclear abnormality on smear

  • 4K55 Cervical cytology test

  • 4KA.. Vaginal vault smear result

  • 4KA1. Vaginal vault smear negative

  • 4KA3. Vaginal vault smear-atrophic

  • 4KA4. Vaginal vault smear abnormal

  • 4KAZ. Vaginal vault smear NOS

  • 685 Cervical neoplasia screen

  • 685.11 Cervical cytology screen

  • 685.12 Cervical smear screen

  • 6856 Ca cervix screen - up to date

  • 6859 Ca cervix - screen done (the default on Cytology Add)

  • 6859.11 Cervical cytology examination

  • 685B Ca cervix screen normal

  • 685C Ca cervix screen abnormal

  • 685D Ca cervix screen + fee claim

  • 685K No smear - no cervix

  • 685M Cervical smear overdue

  • 685Z Ca cervix screen NOS

The following results are flagged as inadequate in Vision 3:

  • 4K21. Cervical smear:inadequate spec

  • 4KA2. Vaginal vault smear-inadequate

  • 6851 Ca cervix screen - not offered

  • 6852 Ca cervix screen - offered

  • 6853. CA cervix screen - not wanted

  • 6854 Ca cervix screen - wanted

  • 6855 Ca cervix screen - not needed

  • 6857. Ca cervix screen - not attended

  • 6858. Ca cervix screen - not reached

  • 6859. Ca cervix - screen done

  • 685A Ca cervix screen-no result yet

  • 685E Cervical smear status unknown

  • 685F Cervical smear due

  • 685G No smear - not sexually active

  • 685H No smear - benign hysterectomy

  • 685H.11 No smear - hysterectomy

  • 685I No smear - amputation of cervix

  • 685J Vaginal vault smear due

  • 4K4.. Cervical smear - action needed

  • 4K41. Cx smear: repeat after treat.

  • 4K42. Cx smear: repeat 1 month

  • 4K43. Cx smear: repeat 3 months

  • 4K44. Cx smear: repeat 4 months

  • 4K45. Cx smear: repeat 6 months

  • 4K46. Cx smear: repeat 9 months

  • 4K47. Cx smear: repeat 12 months

  • 4K48. Cx smear: colposcopy needed

  • 4K49. Cx smear: cervical biopsy needed

  • 4K4A. Cx smear: uterine curet.need

  • 4K4Z. Cervical smear action NOS

  • 4K3 Cervical smear - inflam. change

  • 4K31 Cervical smear - no inflammation

  • 4K32 Cervical smear - severe inflam.

The following are two specific diagnosis codes available in relation to cervical cytology:

  • B831 Carcinoma in situ of cervix uteri

  • K551z Dysplasia of cervix NOS

The 9O8 codes are part of the chapter on Administration, for example, 9O8 Cervical Smear Admin (cervical, smear). They can be used for recall purposes. Searches will mainly be for specific four-digit codes, and both the INCLUDE and the EXCLUDE facility could be used.

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