ICD-10 Coding for Myomectomy(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Myomectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Myomectomy
D25.0-D25.9Primary Range
Leiomyoma of uterus
This range covers all types of uterine fibroids, which are the primary conditions treated by myomectomy.
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 fibroids are located beneath the uterine lining. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when fibroids are located within the uterine wall. |
|
| D25.2 | Subserous leiomyoma of uterus | Use when fibroids are located on the outer wall of the uterus. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use 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 myomectomy
Essential facts and insights about Myomectomy
Primary ICD-10-CM Codes for myomectomy
Decision Criteria
clinical Criteria
- Submucous fibroid confirmed by imaging
Applicable To
- Submucous fibroid
Excludes
- Intramural leiomyoma
- Subserous leiomyoma
Clinical Validation Requirements
- Imaging confirming submucous location
- Pathology report
Code-Specific Risks
- Misclassification if location not specified
Coding Notes
- Ensure the fibroid location is clearly documented.
D25.1 - Intramural leiomyoma of uterus
Use when fibroids are located within the uterine wall.
Applicable To
- Intramural fibroid
Excludes
- Submucous leiomyoma
- Subserous leiomyoma
Clinical Validation Requirements
- Imaging confirming intramural location
- Pathology report
Coding Notes
Ensure the fibroid location is clearly documented.
D25.2 - Subserous leiomyoma of uterus
Use when fibroids are located on the outer wall of the uterus.
Applicable To
- Subserous fibroid
Excludes
- Submucous leiomyoma
- Intramural leiomyoma
Clinical Validation Requirements
- Imaging confirming subserous location
- Pathology report
Coding Notes
Ensure the fibroid location is clearly documented.
D25.9 - Leiomyoma of uterus, unspecified
Use when the fibroid location is not specified in the documentation.
Applicable To
- Unspecified fibroid
Excludes
- Submucous leiomyoma
- Intramural leiomyoma
- Subserous leiomyoma
Clinical Validation Requirements
- Lack of specific location documentation
Coding Notes
Avoid using unless absolutely necessary due to lack of specific location.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Myomectomy 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 representation of surgical complexity., Regulatory: Potential for audit due to incomplete documentation., Financial: May result in lower reimbursement.
Mitigation Strategy
Ensure weight is documented in operative notes., Cross-check with pathology reports.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit., Data Quality: Reduces specificity and accuracy of medical records.
Mitigation Strategy
Ensure the specific location is coded (D25.0, D25.1, or D25.2) based on documentation.
Impact
Frequent use of D25.9 may trigger audits.
Mitigation Strategy
Ensure specific fibroid locations are documented and coded.
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 Myomectomy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Myomectomy
Use these documentation templates to ensure complete and accurate documentation for Myomectomy. These templates include all required elements for proper coding and billing.
Operative Report for Myomectomy
Specialty: GynecologyRequired Elements
- Number of fibroids
- Location of fibroids
- Weight of fibroids
- Surgical approach
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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