ICD-10 Coding for Uterine Myoma(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Uterine Myoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Myoma
D25.0-D25.9Primary Range
Benign neoplasm of uterus
This range includes all types of uterine fibroids based on their 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 submucous as confirmed by imaging. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when fibroid is intramural as confirmed by imaging. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when fibroid is subserosal as confirmed by imaging. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when fibroid location is not specified in 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 uterine myoma
Essential facts and insights about Uterine Myoma
Primary ICD-10-CM Codes for uterine myoma
Decision Criteria
clinical Criteria
- Fibroid location confirmed as submucous
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Ultrasound or MRI showing fibroid protrusion into endometrial cavity
Code-Specific Risks
- Risk of using unspecified code D25.9 when location is known
Coding Notes
- Ensure documentation specifies fibroid location to avoid unspecified coding.
D25.1 - Intramural leiomyoma of uterus
Use when fibroid is intramural as confirmed by imaging.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Imaging showing fibroid within the uterine wall
Coding Notes
Document the number and size of fibroids for accurate coding.
D25.2 - Subserosal leiomyoma of uterus
Use when fibroid is subserosal as confirmed by imaging.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Imaging showing fibroid on the outer uterine wall
Coding Notes
Ensure documentation specifies fibroid location to avoid unspecified coding.
D25.9 - Leiomyoma of uterus, unspecified
Use only when fibroid location is not specified in documentation.
Applicable To
- Unspecified fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Lack of specific location documentation
Coding Notes
Avoid using this code if specific fibroid location is known.
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 Uterine Myoma 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 guidelines, Financial: Potential for incorrect billing and reimbursement
Mitigation Strategy
Use standardized templates for surgical documentation, Verify documentation completeness before coding
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding specificity requirements., Data Quality: Decreases accuracy of medical records.
Mitigation Strategy
Ensure documentation specifies fibroid location to use specific codes like D25.0, D25.1, or D25.2.
Impact
High risk of audit if unspecified codes are used when specific details are available.
Mitigation Strategy
Ensure all documentation includes specific fibroid details to use precise codes.
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 Uterine Myoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Myoma
Use these documentation templates to ensure complete and accurate documentation for Uterine Myoma. These templates include all required elements for proper coding and billing.
Documenting fibroid removal surgery
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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