ICD-10 Coding for Uterine Fibroid(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Uterine Fibroid. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Fibroid
D25Primary Range
Leiomyoma of uterus
This range includes all types of uterine fibroids, categorized by 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 imaging confirms submucosal location. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when imaging confirms intramural location. |
|
| D25.2 | Subserosal leiomyoma of uterus | Use when imaging confirms subserosal location. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use 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 fibroids
Essential facts and insights about Uterine Fibroid
Primary ICD-10-CM Codes for uterine fibroid
Decision Criteria
clinical Criteria
- Imaging confirms submucosal fibroid.
Applicable To
- Submucosal fibroid
Excludes
- Adenomyosis (N85.0)
Clinical Validation Requirements
- Transvaginal ultrasound showing fibroid protruding into the endometrial cavity
Code-Specific Risks
- Incorrect coding if location is not specified.
Coding Notes
- Ensure documentation specifies submucosal location for accurate coding.
D25.1 - Intramural leiomyoma of uterus
Use when imaging confirms intramural location.
Applicable To
- Intramural fibroid
Excludes
- Adenomyosis (N85.0)
Clinical Validation Requirements
- Ultrasound or MRI showing fibroid within the uterine wall.
Coding Notes
Document specific intramural location for accurate coding.
D25.2 - Subserosal leiomyoma of uterus
Use when imaging confirms subserosal location.
Applicable To
- Subserosal fibroid
Excludes
- Adenomyosis (N85.0)
Clinical Validation Requirements
- MRI showing fibroid on the outer surface of the uterus.
Coding Notes
Ensure documentation specifies subserosal location for accurate coding.
D25.9 - Leiomyoma of uterus, unspecified
Use when fibroid location is not specified in documentation.
Applicable To
- Uterine fibroid, NOS
Excludes
- Adenomyosis (N85.0)
Clinical Validation Requirements
- General ultrasound findings without specific location.
Coding Notes
Query for specific location to avoid using unspecified 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.
Adenomyosis of uterus
N85.0Endometriosis of uterus
N80.0Malignant neoplasm of uterus, part unspecified
C55Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine 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: Impacts treatment planning and outcomes., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Standardize documentation templates to include location.
Impact
Reimbursement: May lead to reduced reimbursement due to unspecified coding., Compliance: Increases risk of audit and compliance issues., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Query provider for specific fibroid location.
Impact
High audit risk if fibroid location is not documented.
Mitigation Strategy
Implement mandatory queries for unspecified fibroid locations.
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 Fibroid, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Fibroid
Use these documentation templates to ensure complete and accurate documentation for Uterine Fibroid. These templates include all required elements for proper coding and billing.
Preoperative ultrasound for fibroid evaluation
Specialty: RadiologyRequired Elements
- Indication
- Technique
- Findings
- Impression
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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