Understanding Fibroid Uterus (Uterine Fibroids, Leiomyomas, Myomas) diagnosis, treatment, and management. Find information on Fibroid Uterus symptoms, ICD-10 codes, clinical documentation best practices, and healthcare coding guidelines for Leiomyomas and Myomas. This resource supports accurate medical coding and complete clinical documentation for Uterine Fibroids in healthcare settings.
Also known as
Leiomyoma of uterus
Benign smooth muscle tumors (fibroids) in the uterus.
Other noninflammatory disorders of uterus
Includes other uterine conditions like subinvolution.
Other benign neoplasms of uterus
Benign uterine growths excluding leiomyomas.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient pregnant?
Yes
Is the fibroid complicating pregnancy?
No
Is there torsion of the fibroid?
When to use each related code
| Description |
|---|
| Benign uterine muscle growths. |
| Heavy menstrual bleeding with fibroids. |
| Pelvic pain/pressure due to fibroids. |
Coding fibroids requires specific location (submucosal, intramural, subserosal) for accurate reimbursement and quality reporting. Unspecified location leads to coding errors.
Fibroid size impacts treatment and coding. Documenting and coding precise size is crucial for proper ICD-10-CM code selection and medical necessity validation.
Coding symptoms like menorrhagia or pelvic pain without confirmed fibroid diagnosis leads to inaccurate reporting. Code the confirmed diagnosis, not just symptoms.
Q: What are the most effective minimally invasive surgical techniques for managing symptomatic uterine fibroids in women who desire future fertility?
A: Minimally invasive surgical techniques offer several advantages for women with symptomatic uterine fibroids desiring future fertility. Hysteroscopic myomectomy is highly effective for submucosal fibroids, allowing for removal through the cervix without abdominal incisions. Laparoscopic myomectomy, including robotic-assisted approaches, is appropriate for intramural or subserosal fibroids. These techniques generally result in shorter hospital stays, less postoperative pain, and faster recovery compared to traditional open myomectomy. However, careful consideration of fibroid size, location, and number is crucial for optimal outcome. The surgical approach should be individualized based on the patient's specific clinical presentation and fertility goals. Explore how these techniques compare in terms of fertility outcomes and long-term complications. Consider implementing a shared decision-making approach to guide patients through the available treatment options.
Q: How can clinicians differentiate between uterine fibroids and adenomyosis based on patient symptoms, physical exam findings, and imaging results?
A: Differentiating between uterine fibroids and adenomyosis can be challenging due to overlapping symptoms. While both conditions can cause heavy menstrual bleeding and pelvic pain, some key distinctions exist. Fibroids often present as distinct, palpable masses on physical exam, whereas adenomyosis typically results in a uniformly enlarged, tender uterus. Ultrasound can detect fibroids as well-defined hypoechoic or hyperechoic lesions, while adenomyosis may appear as diffuse myometrial thickening, heterogeneity, or linear striations. MRI provides greater sensitivity and specificity in differentiating the two conditions. Consider the patient's age and parity, as adenomyosis is more common in multiparous women over 40. Learn more about the role of transvaginal ultrasound and MRI in accurately diagnosing and managing these conditions.
Patient presents with symptoms suggestive of uterine fibroids, including heavy menstrual bleeding (menorrhagia), prolonged menstrual periods, pelvic pressure or pain, and urinary frequency. The patient reports a history of symptomatic anemia attributed to heavy menses. Physical examination revealed an enlarged, irregular uterus palpable on bimanual exam. Pelvic ultrasound confirmed the presence of multiple uterine leiomyomas, the largest measuring [size] cm. Differential diagnoses considered included adenomyosis, uterine polyps, and ovarian cysts. Given the patient's symptoms and imaging findings, a diagnosis of fibroid uterus (ICD-10-CM code D25.9, SNOMED CT code 21898003) was established. Treatment options including watchful waiting, medical management with GnRH agonists or other hormonal therapies, and surgical interventions such as uterine artery embolization (UAE) or myomectomy were discussed with the patient. The patient's preference, medical history, and the size and location of the fibroids will guide the treatment plan. Risks and benefits of each option were explained, and the patient elected to proceed with [chosen treatment]. Follow-up scheduled in [timeframe] to assess treatment response and manage any potential complications, such as bleeding, pain, or infection. Patient education provided on fibroid symptoms, treatment options, and potential long-term implications for fertility and uterine health.