ICD-10 Coding for Fibroid(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Fibroid. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fibroid
D25.0-D25.9Primary Range
Benign neoplasm of uterus
This range covers all types of uterine fibroids, categorized by 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 confirmed to be submucosal via imaging. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when fibroid is confirmed to be intramural via imaging. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when fibroid is confirmed to be subserosal via imaging. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when fibroid location cannot be determined. |
|
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 submucosal fibroid
Essential facts and insights about Fibroid
Primary ICD-10-CM Codes for fibroid
Decision Criteria
clinical Criteria
- Confirmed submucosal location via imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Imaging confirming submucosal location
- Symptoms such as menorrhagia
Code-Specific Risks
- Incorrectly coding as intramural or subserosal
Coding Notes
- Ensure imaging confirms submucosal location.
D25.1 - Intramural leiomyoma of uterus
Use when fibroid is confirmed to be intramural via imaging.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Imaging confirming intramural location
- Symptoms such as pelvic pain
Coding Notes
Ensure imaging confirms intramural location.
D25.2 - Subserosal leiomyoma of uterus
Use when fibroid is confirmed to be subserosal via imaging.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Imaging confirming subserosal location
- Symptoms such as pelvic pressure
Coding Notes
Ensure imaging confirms subserosal location.
D25.9 - Leiomyoma of uterus, unspecified
Use only when fibroid location cannot be determined.
Applicable To
- Unspecified fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Lack of specific imaging or surgical confirmation
Coding Notes
Avoid using unless absolutely necessary.
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.
Endometriosis of uterus
N80.0Endometrial hyperplasia
N85.0Malignant neoplasm of uterus, part unspecified
C55Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Fibroid 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 treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Ensure imaging reports specify location., Train staff on documentation requirements.
Impact
Reimbursement: May lead to lower reimbursement or claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always use the most specific code available based on documentation.
Impact
High risk of audit when using unspecified codes without justification.
Mitigation Strategy
Document attempts to determine fibroid location.
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, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fibroid
Use these documentation templates to ensure complete and accurate documentation for Fibroid. These templates include all required elements for proper coding and billing.
Myomectomy for intramural fibroid
Specialty: GynecologyRequired Elements
- Patient symptoms
- Imaging findings
- Surgical details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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