ICD-10 Guide

Uterine Myoma

ICD-10 Coding for Uterine Myoma(D25.0, D25.1, D25.2, D25.9)

PRIMARY SPECIALTYGynecology

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Uterine Myoma?

Essential facts and insights about Uterine Myoma

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: Uterine myoma, leiomyoma, fibroid
Documentation examples: 'Patient presents with heavy menstrual bleeding and pelvic pain. Ultrasound confirms multiple uterine myomas.'

Coding Guidelines

Usage Guidelines & Examples

Usage guidelines: Use specific codes based on the type of myoma.
Common errors: Misclassifying the type of myoma or using unspecified codes.

Code Exclusions

Important Exclusions

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

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 all symptoms, imaging results, and treatment plans.

Billing considerations?

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

Uterine Myoma

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Uterine Myoma

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?