ICD-10 Coding for Uterine Fibroids(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Uterine Fibroids. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Fibroids
D25.0-D25.9Primary Range
Leiomyoma of uterus
This range includes 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 located beneath the endometrial lining. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when fibroid is located within the muscular wall of the uterus. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when fibroid is located on the outer wall of the uterus. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when the specific location of the fibroid 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 submucous leiomyoma
Essential facts and insights about Uterine Fibroids
Primary ICD-10-CM Codes for leiomyoma of uterus
Decision Criteria
clinical Criteria
- Confirmed submucous location via imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus (C54.1)
Clinical Validation Requirements
- Imaging or pathology report confirming submucous location
Code-Specific Risks
- Misclassification if location is not specified
Coding Notes
- Ensure documentation specifies the submucous location to avoid unspecified coding.
D25.1 - Intramural leiomyoma of uterus
Use when fibroid is located within the muscular wall of the uterus.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus (C54.1)
Clinical Validation Requirements
- Imaging or pathology report confirming intramural location
Coding Notes
Ensure documentation specifies the intramural location to avoid unspecified coding.
D25.2 - Subserosal leiomyoma of uterus
Use when fibroid is located on the outer wall of the uterus.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus (C54.1)
Clinical Validation Requirements
- Imaging or pathology report confirming subserosal location
Coding Notes
Ensure documentation specifies the subserosal location to avoid unspecified coding.
D25.9 - Leiomyoma of uterus, unspecified
Use only when the specific location of the fibroid cannot be determined.
Applicable To
- Unspecified fibroid
Excludes
- Malignant neoplasm of uterus (C54.1)
Clinical Validation Requirements
- Used only when specific location cannot be determined
Coding Notes
Avoid using this code if the location of the fibroid is known.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Excessive and frequent menstruation with regular cycle
N92.0Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Endometriosis of uterus
N80.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine Fibroids to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D25.0.
Impact
Clinical: Leads to inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Train staff on the importance of detailed documentation., Use templates to ensure completeness.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of health records.
Mitigation Strategy
Ensure documentation specifies the fibroid location to use the correct code.
Impact
Using D25.9 when specific location is documented.
Mitigation Strategy
Ensure documentation supports the most specific code.
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 Fibroids, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Fibroids
Use these documentation templates to ensure complete and accurate documentation for Uterine Fibroids. These templates include all required elements for proper coding and billing.
Documenting Uterine Fibroids
Specialty: GynecologyRequired Elements
- Fibroid location
- Size and number
- Symptoms and correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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