ICD-10 Coding for Fibroid Uterus(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Fibroid Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fibroid Uterus
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 imaging confirms a submucosal fibroid protruding into the endometrial cavity. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when imaging confirms an intramural fibroid located within the myometrium. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when imaging confirms a subserosal fibroid with predominant extramural extension. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when 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 fibroid uterus
Essential facts and insights about Fibroid Uterus
Primary ICD-10-CM Codes for fibroid uterus
Decision Criteria
clinical Criteria
- Imaging confirms submucosal fibroid
Applicable To
- Submucosal fibroid
Excludes
- Endometrial polyp (N84.0)
Clinical Validation Requirements
- Imaging showing >50% intracavitary component
- FIGO Type 0-2
Code-Specific Risks
- Misclassification if location is not specified
Coding Notes
- Ensure documentation specifies the submucosal location to avoid using unspecified codes.
D25.1 - Intramural leiomyoma of uterus
Use when imaging confirms an intramural fibroid located within the myometrium.
Applicable To
- Intramural fibroid
Excludes
- Degenerating fibroid (O34.20)
Clinical Validation Requirements
- 3D ultrasound confirming fibroid entirely within myometrium
Coding Notes
Document the size and location within the myometrium to ensure accurate coding.
D25.2 - Subserosal leiomyoma of uterus
Use when imaging confirms a subserosal fibroid with predominant extramural extension.
Applicable To
- Subserosal fibroid
Excludes
- Pedunculated fibroid (D25.2)
Clinical Validation Requirements
- MRI evidence of outer mantle >50% extramural
Coding Notes
Ensure documentation specifies the subserosal location to avoid using unspecified codes.
D25.9 - Leiomyoma of uterus, unspecified
Use only when fibroid location is not specified in the documentation.
Applicable To
- Unspecified fibroid
Excludes
- Specific fibroid types (D25.0-D25.2)
Clinical Validation Requirements
- Lack of specific location documentation
Coding Notes
Encourage documentation specificity to avoid using this code.
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 Fibroid Uterus 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 assessment of treatment needs., Regulatory: Non-compliance with coding guidelines., Financial: Potential loss of reimbursement.
Mitigation Strategy
Ensure imaging reports include size, Verify documentation before coding
Impact
Reimbursement: Lower reimbursement due to unspecified code usage., Compliance: Increased audit risk for lack of specificity., Data Quality: Decreased data quality and clinical accuracy.
Mitigation Strategy
Query for specific fibroid location to use a more specific code.
Impact
Using D25.9 due to lack of specific location documentation.
Mitigation Strategy
Encourage detailed imaging and clinical 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 Fibroid Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fibroid Uterus
Use these documentation templates to ensure complete and accurate documentation for Fibroid Uterus. These templates include all required elements for proper coding and billing.
Gynecology Progress Note
Specialty: GynecologyRequired Elements
- Patient symptoms
- Imaging findings
- Fibroid location and size
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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