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ICD-10 Guide
ICD-10 CodesD26.9

D26.9

Billable

Other benign neoplasm of uterus, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 D26.9 is a billable code used to indicate a diagnosis of other benign neoplasm of uterus, unspecified.

Key Diagnostic Point:

D26.9 refers to other benign neoplasms of the uterus that are not specified in detail. Benign neoplasms of the uterus can include a variety of growths such as fibroids (leiomyomas), adenomyomas, and other non-cancerous tumors. These neoplasms can arise from the smooth muscle or connective tissue of the uterus and may present with symptoms such as abnormal uterine bleeding, pelvic pain, or pressure symptoms. Diagnosis is typically made through imaging studies such as ultrasound or MRI, and histological examination may be required for definitive diagnosis. Management options vary based on the size, location, and symptoms associated with the neoplasm, ranging from watchful waiting to surgical interventions like myomectomy or hysterectomy. Follow-up care is essential to monitor for any changes in the neoplasm or the emergence of new symptoms.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of benign neoplasms
  • Need for precise differentiation from malignant conditions
  • Potential for overlapping symptoms with other gynecological conditions
  • Variability in treatment approaches and follow-up requirements

Audit Risk Factors

  • Insufficient documentation of symptoms and treatment
  • Failure to differentiate between benign and malignant neoplasms
  • Inconsistent follow-up documentation
  • Lack of imaging or pathology reports to support diagnosis

Specialty Focus

Medical Specialties

Gynecology

Documentation Requirements

Detailed patient history, imaging results, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with pelvic pain, abnormal bleeding, or findings on imaging suggestive of a uterine neoplasm.

Billing Considerations

Ensure clear documentation of the type of neoplasm and any associated symptoms to avoid misclassification.

Radiology

Documentation Requirements

Imaging reports must clearly describe the characteristics of the neoplasm.

Common Clinical Scenarios

Ultrasound or MRI findings indicating the presence of a uterine mass.

Billing Considerations

Radiologists should provide detailed descriptions to assist in accurate coding.

Coding Guidelines

Inclusion Criteria

Use D26.9 When
  • According to ICD
  • 10 guidelines, D26
  • 9 should be used when a benign neoplasm of the uterus is diagnosed but not specified further
  • Coders should ensure that the documentation supports the diagnosis and that no more specific code is applicable

Exclusion Criteria

Do NOT use D26.9 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58150CPT Code

Total abdominal hysterectomy

Clinical Scenario

Used when a patient with a benign uterine neoplasm undergoes a hysterectomy.

Documentation Requirements

Operative report detailing the procedure and indication.

Specialty Considerations

Gynecologists should ensure clear documentation of the diagnosis and rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding, but D26.9 remains a broad code that requires careful documentation to avoid misclassification and ensure appropriate reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding, but D26.9 remains a broad code that requires careful documentation to avoid misclassification and ensure appropriate reimbursement.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms associated with benign neoplasms of the uterus?

Common symptoms include abnormal uterine bleeding, pelvic pain, and pressure symptoms. Some patients may be asymptomatic.

When should D26.9 be used instead of a more specific code?

D26.9 should be used when the specific type of benign neoplasm is not documented or when the neoplasm does not fit into other specific categories.