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ICD-10 Guide
ICD-10 CodesD25.0

D25.0

Billable

Submucous leiomyoma of uterus

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

Code Description

ICD-10 D25.0 is a billable code used to indicate a diagnosis of submucous leiomyoma of uterus.

Key Diagnostic Point:

Submucous leiomyomas, also known as submucosal fibroids, are benign tumors that develop within the muscular layer of the uterus, specifically protruding into the uterine cavity. These tumors are composed of smooth muscle and fibrous tissue and can vary in size. They are often asymptomatic but can lead to significant clinical issues such as heavy menstrual bleeding, pelvic pain, and reproductive complications. The presence of submucous leiomyomas can interfere with normal uterine function and may contribute to infertility or pregnancy complications. Diagnosis is typically made through imaging studies such as ultrasound or MRI, and the management may include medical therapy, minimally invasive procedures, or surgical interventions depending on the severity of symptoms and the patient's reproductive plans. Regular follow-up is essential to monitor the growth of the leiomyoma and the patient's symptoms, especially in cases where conservative management is chosen.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from other types of uterine fibroids (intramural, subserosal)
  • Need for precise documentation of symptoms and imaging findings
  • Potential for associated conditions (e.g., menorrhagia, infertility)
  • Variability in treatment options and their documentation

Audit Risk Factors

  • Inadequate documentation of symptoms related to the leiomyoma
  • Failure to specify the type of leiomyoma
  • Misalignment between diagnosis and treatment codes
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

Detailed documentation of symptoms, imaging results, and treatment plans.

Common Clinical Scenarios

Management of heavy menstrual bleeding, infertility evaluations, and preoperative assessments.

Billing Considerations

Ensure that the type and location of the leiomyoma are clearly documented to support the coding.

Radiology

Documentation Requirements

Clear imaging reports indicating the size, location, and characteristics of the leiomyoma.

Common Clinical Scenarios

Ultrasound or MRI evaluations for suspected fibroids.

Billing Considerations

Radiologists should provide detailed descriptions to aid in accurate coding.

Coding Guidelines

Inclusion Criteria

Use D25.0 When
  • According to official coding guidelines, D25
  • 0 should be used when the submucous leiomyoma is confirmed through imaging or surgical findings
  • It is important to document the patient's symptoms and any related conditions to support the diagnosis

Exclusion Criteria

Do NOT use D25.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58140CPT Code

Myomectomy, excision of uterine leiomyoma

Clinical Scenario

Used when a patient with a submucous leiomyoma undergoes surgical removal.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Obstetricians should ensure that the diagnosis aligns with the surgical procedure performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of leiomyomas, improving the accuracy of diagnoses and treatment tracking. D25.0 provides a clear distinction for submucous leiomyomas, which can impact treatment decisions and patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of leiomyomas, improving the accuracy of diagnoses and treatment tracking. D25.0 provides a clear distinction for submucous leiomyomas, which can impact treatment decisions and patient management.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    American College of Obstetricians and Gynecologists (ACOG)

Coding & Billing References

  • •
    American College of Obstetricians and Gynecologists (ACOG)

Frequently Asked Questions

What are the common symptoms of submucous leiomyomas?

Common symptoms include heavy menstrual bleeding, pelvic pain, and pressure symptoms. Some patients may also experience infertility.

How are submucous leiomyomas diagnosed?

Diagnosis is typically made through pelvic ultrasound or MRI, which can visualize the location and size of the leiomyoma.

What treatment options are available for submucous leiomyomas?

Treatment options include medical management with hormonal therapies, minimally invasive procedures like hysteroscopic myomectomy, or surgical options such as abdominal myomectomy or hysterectomy.