ICD-10 Coding for Leiomyoma(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Leiomyoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Leiomyoma
D25.0-D25.9Primary Range
Leiomyoma of uterus
This range covers all types of uterine leiomyomas, including submucous, intramural, subserous, and unspecified.
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 submucosal and causing symptoms like menorrhagia. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when the fibroid is intramural and causing symptoms like bulk symptoms. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when the fibroid is subserosal and causing symptoms like torsion pain. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use when the fibroid location is unspecified and no symptoms are present. |
|
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 submucous leiomyoma
Essential facts and insights about Leiomyoma
Primary ICD-10-CM Codes for leiomyoma
Decision Criteria
clinical Criteria
- Presence of submucosal fibroid with menorrhagia
Applicable To
- Submucosal fibroid
Excludes
- Leiomyosarcoma (C54.2)
Clinical Validation Requirements
- Fibroid distorting endometrial cavity with menorrhagia
- Submucosal fibroid visualized on hysteroscopy
Code-Specific Risks
- Misclassification if fibroid location is not specified
Coding Notes
- Ensure documentation specifies submucosal location.
D25.1 - Intramural leiomyoma of uterus
Use when the fibroid is intramural and causing symptoms like bulk symptoms.
Applicable To
- Intramural fibroid
Excludes
- Leiomyosarcoma (C54.2)
Clinical Validation Requirements
- Fibroid causing bulk symptoms without cavity distortion
- Intramural fibroid measuring ≥5 cm
Coding Notes
Ensure documentation specifies intramural location.
D25.2 - Subserosal leiomyoma of uterus
Use when the fibroid is subserosal and causing symptoms like torsion pain.
Applicable To
- Subserosal fibroid
Excludes
- Leiomyosarcoma (C54.2)
Clinical Validation Requirements
- Pedunculated fibroid causing torsion pain
- Subserosal fibroid on ultrasound with free pelvic fluid
Coding Notes
Ensure documentation specifies subserosal location.
D25.9 - Leiomyoma of uterus, unspecified
Use when the fibroid location is unspecified and no symptoms are present.
Applicable To
- Unspecified uterine fibroid
Excludes
- Leiomyosarcoma (C54.2)
Clinical Validation Requirements
- Incidental finding on imaging without symptoms
- Asymptomatic uterine leiomyoma noted on CT
Coding Notes
Avoid use when specific fibroid location is documented.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Leiomyoma 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 clinical data, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Pre-op imaging review, Intraoperative documentation template
Impact
Reimbursement: Potential claim denial or reduced payment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate data representation
Mitigation Strategy
Amend to specific location code with surgeon's addendum
Impact
High audit risk if D25.9 is used with surgical procedures
Mitigation Strategy
Use specific location codes when possible
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 Leiomyoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Leiomyoma
Use these documentation templates to ensure complete and accurate documentation for Leiomyoma. These templates include all required elements for proper coding and billing.
Gynecology Progress Note
Specialty: GynecologyRequired Elements
- Symptom attribution
- Imaging correlation
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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