Find comprehensive information on myomectomy, including clinical documentation requirements, CPT and ICD-10 codes, postoperative care, and recovery. This resource covers uterine fibroid removal surgery, laparoscopic myomectomy, abdominal myomectomy, hysteroscopic myomectomy, and myomectomy complications. Learn about medical coding guidelines for myomectomy procedures and ensure accurate healthcare documentation for optimal reimbursement. Explore the latest advancements in myomectomy techniques and best practices for patient care.
Also known as
Leiomyoma of uterus
Covers uterine fibroids, the condition myomectomy treats.
Encounter for childbirth
May be relevant if myomectomy is performed during childbirth.
Noninflammatory disorders of female genital tract
Includes other uterine conditions that might necessitate myomectomy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the myomectomy performed via laparoscopy?
Yes
Robotic assistance used?
No
Was it performed via hysteroscopy?
When to use each related code
| Description |
|---|
| Surgical fibroid removal |
| Hysterectomy |
| Uterine artery embolization |
Using unlisted myomectomy codes when a specific code exists, leading to claim denials and inaccurate data.
Incorrect coding of the surgical approach (e.g., laparoscopic, abdominal) impacting reimbursement and quality metrics.
Failure to accurately code morcellation or associated complications creates compliance and billing issues.
Patient presents with symptomatic uterine fibroids (leiomyomas), confirmed by pelvic examination and imaging (ultrasound or MRI). Chief complaints include heavy menstrual bleeding (menorrhagia), prolonged menstrual periods (hypermenorrhea), pelvic pain and pressure, and or bulk symptoms such as urinary frequency or constipation. The diagnosis of uterine fibroids is established based on clinical findings and imaging results. Patient desires to preserve fertility and undergoes an abdominal myomectomy for the removal of the fibroids. Intraoperative findings revealed multiple intramural and subserosal fibroids. The procedure was performed without complications. Estimated blood loss was minimal. Uterus was repaired in multiple layers. Postoperative course was unremarkable. Patient tolerated the procedure well and was discharged on postoperative day one with instructions for pain management and follow-up. Final pathology confirmed benign leiomyomas. ICD-10 code D25.1 (leiomyoma of uterus) and CPT code 58140 (abdominal myomectomy for multiple fibroids) are appropriate for this case. Patient education regarding the risks and benefits of myomectomy versus other treatment options, such as hysterectomy or uterine artery embolization (UAE), was documented. Discussion included potential complications such as bleeding, infection, recurrence of fibroids, and the possibility of needing a cesarean section in future pregnancies. Follow-up care includes monitoring for symptom recurrence and assessing for fertility.