Find comprehensive information on uterine fibroids, including symptoms, diagnosis, treatment options like UFE or myomectomy, and ICD-10 coding (D25.x). Learn about clinical documentation requirements for leiomyoma, fibroid uterus, and related pelvic pain, abnormal uterine bleeding, or bulk symptoms. Explore resources for healthcare professionals on managing uterine fibroids and optimizing patient care.
Also known as
Leiomyoma of uterus
Benign tumors (fibroids) in the muscular wall of the uterus.
Endometriosis
Uterine tissue grows outside the uterus, sometimes causing similar symptoms to fibroids.
Pelvic and abdominal pain
Pain in the lower abdomen, a common symptom of uterine fibroids.
Other specified noninflammatory disorders of female genital organs
Can include specific types or complications of fibroids not covered in D25.
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 |
|---|
| Uterine Fibroids |
| Adenomyosis |
| Leiomyosarcoma |
Coding requires specific fibroid type (e.g., submucosal, intramural). Lack of documentation can lead to inaccurate coding (e.g., D25.0 vs. D25.1).
Fibroid symptoms (e.g., menorrhagia, pelvic pain) should be coded separately. Omitting symptom codes impacts data accuracy and reimbursement.
Fibroid size impacts management and coding. Missing size information hinders accurate code assignment and quality reporting.
Patient presents with symptoms suggestive of uterine fibroids, including heavy menstrual bleeding (menorrhagia), prolonged menstrual periods, pelvic pressure or pain, and frequent urination. Physical examination reveals an enlarged, irregular uterus palpable on bimanual exam. Pelvic ultrasound confirms the presence of multiple uterine leiomyomas, consistent with a diagnosis of uterine fibroids. The largest fibroid measures [size] cm in diameter. Differential diagnoses considered include adenomyosis, uterine polyps, and pelvic masses. Patient reports no significant past medical history of gynecological issues. She denies fever, chills, or abnormal vaginal discharge. Current symptoms are impacting her quality of life, interfering with daily activities and causing significant discomfort. Assessment includes uterine fibroids, symptomatic. Plan includes discussion of management options, including watchful waiting, medical management with hormonal therapy such as gonadotropin-releasing hormone agonists or oral contraceptives, and surgical interventions such as myomectomy or hysterectomy. Risks and benefits of each treatment option were explained to the patient. Patient will follow up in [timeframe] to discuss her decision regarding treatment and for ongoing symptom management. ICD-10 code D25.9 (leiomyoma of uterus, unspecified) is documented. CPT codes for the visit and ultrasound will be added upon completion of the encounter. Patient education provided on uterine fibroid symptoms, treatment options, and potential complications.