Diagnosis Overview

What is Myoma Uteri?

Essential facts and insights about Myoma Uteri

Key Clinical Considerations:

Heavy menstrual bleeding (menorrhagia)
Pelvic pain or pressure
Frequent urination or difficulty emptying the bladder
Key diagnostic tests: Ultrasound, MRI
Physical exam findings: Enlarged uterus, palpable masses

Clinical Information

Clinical Criteria & Documentation Requirements

Required documentation elements: Patient history, symptom description, imaging results
Specific coding terminology: Myoma, leiomyoma, fibroid
Documentation examples: 'Patient presents with menorrhagia and pelvic pressure; ultrasound confirms multiple myomas.'

Coding Guidelines

Usage Guidelines & Examples

Usage guidelines: Use specific codes based on myoma type for accurate billing.
Common errors: Misclassifying the type of myoma or failing to document symptoms.

Code Exclusions

Important Exclusions

Excluded conditions: Uterine cancer, endometrial hyperplasia.
Alternative codes: Consider using codes for related conditions if applicable.

Related ICD-10 Codes

Primary Codes

D25.9

Uterine leiomyoma, unspecified

D25.0

Submucous leiomyoma of uterus

D25.1

Intramural leiomyoma of uterus

D25.2

Subserosal leiomyoma of uterus

Ancillary Codes

N92.0

N92.1

Differential Codes

D25.1

if fibroid is located within the uterine wall.

D25.2

if fibroid is located on the outer surface of the uterus.

D25.0

if fibroid is located beneath the endometrium.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Gynecology

Specialty Applications

Patient populations: Women of reproductive age, particularly those with heavy menstrual bleeding.
Clinical settings: Gynecology clinics, outpatient surgery centers.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Document patient symptoms, imaging results, and treatment plans.

Billing considerations?

Ensure accurate coding based on the type and location of myomas.