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D25.9
ICD-10-CM
Myomatous Uterus

Find comprehensive information on myomatous uterus, including clinical documentation, medical coding, ICD-10 codes (B57), uterine fibroids, leiomyoma, and myoma. Learn about diagnosis, treatment, and management of myomatous uterus for healthcare professionals and patients. Explore resources related to symptomatology, imaging, and differential diagnosis for a complete understanding of this common uterine condition.

Also known as

Uterine Fibroids
Leiomyomas

Diagnosis Snapshot

Key Facts
  • Definition : Benign smooth muscle tumors (fibroids) in the uterus.
  • Clinical Signs : Heavy bleeding, pelvic pain, frequent urination, abdominal swelling.
  • Common Settings : Gynecologist office, outpatient surgery center, hospital.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC D25.9 Coding
D25.0-D25.9

Leiomyoma of uterus

Benign tumors (fibroids) in the muscular wall of the uterus.

N85.0-N85.9

Other noninflammatory disorders of uterus

Includes other uterine conditions not classified elsewhere, such as adenomyosis.

D26.0-D26.9

Other benign neoplasms of uterus

Includes other benign growths in the uterus besides leiomyomas.

R10.0-R10.9

Pelvic and perineal pain

May be a symptom associated with uterine fibroids.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the myoma symptomatic?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Uterine fibroids
Adenomyosis
Endometrial polyps

Documentation Best Practices

Documentation Checklist
  • Myomatous uterus: Document size, number, location
  • Uterine fibroids: Symptom documentation (e.g., bleeding, pain)
  • Fibroid diagnosis: Imaging confirmation (ultrasound, MRI)
  • Myoma size: Measured in centimeters, if applicable
  • Document impact on fertility if relevant

Coding and Audit Risks

Common Risks
  • Unspecified Location

    Coding myomatous uterus without specifying location (submucosal, intramural, subserosal) leads to inaccurate documentation and potential downcoding.

  • Symptom Coding

    Coding symptoms like bleeding or pain instead of the underlying myomatous uterus misrepresents the diagnosis and impacts quality metrics.

  • Size Documentation

    Lack of size documentation for myomatous uterus affects accurate coding, especially for procedures, and may trigger audits for medical necessity.

Mitigation Tips

Best Practices
  • Code accurately: Uterine leiomyoma (D25.x)
  • Document size, location, symptoms for D25.x
  • Submucosal fibroids? Specify type for ICD-10
  • CDI: Review 'fibroid' vs 'leiomyoma' usage
  • Ensure medical necessity for procedures (NCCI edits)

Clinical Decision Support

Checklist
  • Confirm pelvic exam/imaging shows uterine fibroids.
  • Document fibroid size, location, and symptoms.
  • Assess for anemia (CBC).
  • Exclude other pelvic pathologies (e.g., adenomyosis).
  • Code diagnosis (ICD-10: D25.9, SNOMED: 127447004)

Reimbursement and Quality Metrics

Impact Summary
  • Myomatous Uterus: Coding accuracy impacts DRG assignment and reimbursement.
  • Accurate ICD-10 coding (e.g., D25.x) for fibroids ensures appropriate hospital payment.
  • Quality metrics for Myomatous Uterus include surgical complications and readmission rates.
  • Proper documentation and coding improve data integrity for public health reporting.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code fibroid location/size
  • Specify symptom impact
  • Document type: submucosal/intramural
  • Note any related procedures
  • Use ICD-10 D25.x codes

Documentation Templates

Patient presents with complaints consistent with symptomatic uterine fibroids (leiomyomas, myomas).  Presenting symptoms include heavy menstrual bleeding (menorrhagia), prolonged menstrual periods (hypermenorrhea), pelvic pressure or pain, and urinary frequency.  Physical examination reveals an enlarged, irregularly shaped uterus palpable on bimanual exam.  Pelvic ultrasound confirms the presence of multiple uterine fibroids, the largest measuring [size] cm in diameter.  Differential diagnosis includes adenomyosis, endometrial polyps, and pelvic masses.  Assessment:  Myomatous uterus (ICD-10 G25.1).  Plan:  Discussed treatment options including watchful waiting, medical management with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and hormonal therapy (e.g., GnRH agonists, oral contraceptives) to control bleeding, and surgical interventions such as uterine artery embolization (UAE) or myomectomy. Patient education provided regarding the risks and benefits of each option.  Patient will follow up in [timeframe] to discuss treatment plan and symptom management.  Medical coding and billing will reflect the evaluation and management (E/M) service provided, as well as the ultrasound procedure.