ICD-10 Coding for Myoma Uteri(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Myoma Uteri. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Myoma Uteri
D25.0-D25.9Primary Range
Leiomyoma of uterus
This range covers all types of uterine fibroids, categorized by location.
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 fibroid is confirmed to be submucous by imaging or surgical report. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when fibroid is confirmed to be intramural by imaging or surgical report. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when fibroid is confirmed to be subserosal by imaging or surgical report. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use when the location of the fibroid 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 myoma uteri
Essential facts and insights about Myoma Uteri
Primary ICD-10-CM Codes for myoma uteri
Decision Criteria
clinical Criteria
- Submucous location confirmed by imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Hysteroscopy or HSG report confirming submucous location
Code-Specific Risks
- Incorrect use if location is not specified, leading to claim denials.
Coding Notes
- Ensure documentation specifies submucous location to avoid denials.
D25.1 - Intramural leiomyoma of uterus
Use when fibroid is confirmed to be intramural by imaging or surgical report.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- MRI or ultrasound confirming intramural location
Coding Notes
Ensure documentation specifies intramural location to avoid denials.
D25.2 - Subserosal leiomyoma of uterus
Use when fibroid is confirmed to be subserosal by imaging or surgical report.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Ultrasound or surgical report confirming subserosal location
Coding Notes
Ensure documentation specifies subserosal location to avoid denials.
D25.9 - Leiomyoma of uterus, unspecified
Use when the location of the fibroid is not specified in the documentation.
Applicable To
- Fibroid NOS
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- General documentation of uterine fibroid without specific location
Coding Notes
Avoid using D25.9 when specific location is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Myoma Uteri 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 records., Regulatory: Non-compliance with coding standards., Financial: Reduced reimbursement due to lower CPT code usage.
Mitigation Strategy
Ensure weight is documented in operative notes.
Impact
Reimbursement: Potential claim denials and reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data collection and reporting.
Mitigation Strategy
Ensure documentation specifies the fibroid location to use the correct code.
Impact
High risk of audit for using D25.9 without attempting to specify location.
Mitigation Strategy
Implement mandatory location documentation in all reports.
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 Myoma Uteri, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Myoma Uteri
Use these documentation templates to ensure complete and accurate documentation for Myoma Uteri. These templates include all required elements for proper coding and billing.
Surgical removal of uterine fibroids
Specialty: GynecologyRequired Elements
- Number of fibroids
- Weight of fibroids
- Location of fibroids
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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