ICD-10 Coding for Uterine Leiomyoma(D25.0, D25.1, D25.2, D25.9)
Complete ICD-10-CM coding and documentation guide for Uterine Leiomyoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Uterine Leiomyoma
D25.0-D25.9Primary Range
Leiomyoma of uterus
This range covers all types of uterine leiomyomas, including submucous, intramural, subserous, and unspecified types.
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 documentation specifies submucous fibroid confirmed by imaging. |
|
| D25.1 | Intramural leiomyoma of uterus | Use when documentation specifies intramural fibroid confirmed by imaging. |
|
| D25.2 | Subserous leiomyoma of uterus | Use when documentation specifies subserous fibroid confirmed by imaging. |
|
| D25.9 | Leiomyoma of uterus, unspecified | Use only when documentation does not specify fibroid type or location. |
|
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 leiomyoma
Essential facts and insights about Uterine Leiomyoma
Primary ICD-10-CM Codes for uterine leiomyoma
Decision Criteria
clinical Criteria
- Presence of submucous fibroid on imaging
Applicable To
- Submucosal fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Imaging showing fibroid projecting into endometrial cavity
Code-Specific Risks
- Risk of using unspecified codes when specific location is documented.
Coding Notes
- Ensure documentation specifies fibroid type and location.
D25.1 - Intramural leiomyoma of uterus
Use when documentation specifies intramural fibroid confirmed by imaging.
Applicable To
- Intramural fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Ultrasound or MRI showing fibroid within the uterine wall
Coding Notes
Ensure documentation specifies fibroid type and location.
D25.2 - Subserous leiomyoma of uterus
Use when documentation specifies subserous fibroid confirmed by imaging.
Applicable To
- Subserosal fibroid
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- Imaging showing fibroid on outer uterine surface
Coding Notes
Ensure documentation specifies fibroid type and location.
D25.9 - Leiomyoma of uterus, unspecified
Use only when documentation does not specify fibroid type or location.
Applicable To
- Uterine fibroid NOS
Excludes
- Malignant neoplasm of uterus (C55)
Clinical Validation Requirements
- General documentation of uterine fibroid without specific location
Coding Notes
Avoid using unspecified codes when specific details are available.
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.
Malignant neoplasm of uterus
C55Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Uterine Leiomyoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code D25.0.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit and non-compliance., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Ensure imaging reports are included in the medical record., Train staff on the importance of detailed documentation.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement issues., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies fibroid type and location, and use the corresponding specific code.
Impact
High risk of audit when using D25.9 without justification.
Mitigation Strategy
Ensure documentation includes specific 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 Uterine Leiomyoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Uterine Leiomyoma
Use these documentation templates to ensure complete and accurate documentation for Uterine Leiomyoma. These templates include all required elements for proper coding and billing.
Intramural fibroid with menorrhagia
Specialty: GynecologyRequired Elements
- Patient history including symptoms
- Imaging results specifying fibroid type and size
- Treatment plan and follow-up
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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