ICD-10 Coding for Fibroids(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Fibroids. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fibroids
D25.0-D25.9Primary Range
Benign neoplasm of uterus
This range covers all types of uterine fibroids, categorized by their location within the uterus.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| D25.0 | Submucous leiomyoma of uterus | Use when the fibroid is located beneath the endometrial lining, causing cavity distortion. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when the fibroid is located within the muscular wall of the uterus. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when the fibroid is located on the outer surface of the uterus. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when the fibroid location is not specified in the documentation. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for submucosal fibroids
Essential facts and insights about Fibroids
Primary ICD-10-CM Codes for fibroids
Decision Criteria
clinical Criteria
- Presence of submucosal fibroid confirmed by imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Ultrasound or MRI showing submucosal fibroid
- Symptoms of menorrhagia or infertility
Code-Specific Risks
- Incorrectly coding as D25.9 when submucosal location is specified
Coding Notes
- Ensure documentation specifies submucosal location to avoid denials.
D25.1 - Intramural leiomyoma of uterus
Use when the fibroid is located within the muscular wall of the uterus.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Imaging showing fibroid within the uterine wall
- Symptoms such as pelvic pain or pressure
Coding Notes
Document fibroid size and number for accurate coding.
D25.2 - Subserosal leiomyoma of uterus
Use when the fibroid is located on the outer surface of the uterus.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Imaging showing fibroid on the outer uterine surface
- Symptoms like bladder pressure
Coding Notes
Ensure documentation specifies subserosal location.
D25.9 - Leiomyoma of uterus, unspecified
Use only when the fibroid location is not specified in the documentation.
Applicable To
- Unspecified fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- General fibroid diagnosis without specific location
Coding Notes
Avoid using unless absolutely necessary; specify location if possible.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Excessive and frequent menstruation with regular cycle
N92.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Endometriosis of uterus
N80.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Fibroids to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D25.0.
Impact
Clinical: Inaccurate surgical planning and follow-up, Regulatory: Non-compliance with coding guidelines, Financial: Potential for reduced reimbursement
Mitigation Strategy
Standardize surgical report templates to include weight, Educate staff on documentation requirements
Impact
Reimbursement: Potential for reduced reimbursement due to unspecified coding, Compliance: Non-compliance with coding specificity requirements, Data Quality: Decreased accuracy in clinical data reporting
Mitigation Strategy
Use D25.0, D25.1, or D25.2 based on fibroid location
Impact
Using unspecified codes when specific codes are applicable
Mitigation Strategy
Educate coders on the importance of specific fibroid location documentation
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Fibroids, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fibroids
Use these documentation templates to ensure complete and accurate documentation for Fibroids. These templates include all required elements for proper coding and billing.
Surgical planning for fibroid removal
Specialty: GynecologyRequired Elements
- Fibroid location
- Fibroid size
- Fibroid number
- Symptoms
- Prior treatments
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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