ICD-10 Coding for Myomatous Uterus(D25.0, D25.1)
Complete ICD-10-CM coding and documentation guide for Myomatous Uterus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Myomatous Uterus
D25.0-D25.9Primary Range
Benign neoplasm of uterus
This range covers all types of uterine fibroids, including submucosal, intramural, and subserosal.
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 uterine wall. |
|
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 myomatous uterus
Essential facts and insights about Myomatous Uterus
Primary ICD-10-CM Codes for myomatous uterus
Decision Criteria
clinical Criteria
- Presence of submucosal fibroid on imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Ultrasound or MRI showing submucosal fibroid
- Symptoms of heavy menstrual bleeding
Code-Specific Risks
- Misclassification if location is not specified
Coding Notes
- Ensure fibroid location is documented to avoid unspecified coding.
D25.1 - Intramural leiomyoma of uterus
Use when fibroid is located within the uterine wall.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus
Clinical Validation Requirements
- Imaging showing intramural fibroid
- Symptoms such as pelvic pain
Coding Notes
Document the number and size of fibroids for accurate coding.
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 Myomatous 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 treatment planning, Regulatory: Non-compliance with documentation standards, Financial: Potential loss of reimbursement
Mitigation Strategy
Use standardized templates for operative reports, Ensure imaging reports specify fibroid details
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of health records.
Mitigation Strategy
Always document and code the specific type of fibroid (e.g., D25.0, D25.1).
Impact
Using unspecified codes when specific details are available.
Mitigation Strategy
Implement mandatory fields in EHR for fibroid type and 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 Myomatous Uterus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Myomatous Uterus
Use these documentation templates to ensure complete and accurate documentation for Myomatous Uterus. These templates include all required elements for proper coding and billing.
Operative Report for Myomectomy
Specialty: GynecologyRequired Elements
- Number of fibroids removed
- Size and location of each fibroid
- Total weight of fibroids
- Pathology confirmation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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