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ICD-10 Guide
ICD-10 CodesD25.1

D25.1

Billable

Intramural leiomyoma of uterus

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

Code Description

ICD-10 D25.1 is a billable code used to indicate a diagnosis of intramural leiomyoma of uterus.

Key Diagnostic Point:

Intramural leiomyomas, commonly known as uterine fibroids, are benign tumors that develop within the muscular wall of the uterus. These tumors are composed of smooth muscle and fibrous tissue and can vary in size, number, and location. Intramural leiomyomas can cause a range of symptoms, including heavy menstrual bleeding, pelvic pain, and pressure symptoms affecting the bladder or bowel. Diagnosis is typically made through pelvic examination, ultrasound, or MRI. While many women with intramural leiomyomas remain asymptomatic, those experiencing significant symptoms may require treatment options such as medication, uterine artery embolization, or surgical interventions like myomectomy or hysterectomy. Management strategies depend on the size and location of the fibroids, the severity of symptoms, and the patient's reproductive plans. Follow-up care is essential to monitor for changes in symptoms or the development of new fibroids, particularly in women of reproductive age.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptom presentation among patients
  • Need for imaging studies for accurate diagnosis
  • Differentiation from other types of uterine fibroids
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to document imaging results
  • Incorrect coding of fibroid type or location
  • Lack of follow-up documentation post-treatment

Specialty Focus

Medical Specialties

Obstetrics and Gynecology

Documentation Requirements

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

Common Clinical Scenarios

Management of symptomatic fibroids, pre-operative assessments, and post-operative follow-ups.

Billing Considerations

Consideration of patient’s reproductive goals and potential impact of treatment on fertility.

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

Accurate imaging interpretation is crucial for proper coding and treatment planning.

Coding Guidelines

Inclusion Criteria

Use D25.1 When
  • According to ICD
  • 10 guidelines, D25
  • 1 should be used when the diagnosis of intramural leiomyoma is confirmed through imaging or clinical evaluation
  • It is important to document the size and location of the fibroid and any associated symptoms

Exclusion Criteria

Do NOT use D25.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58140CPT Code

Total abdominal hysterectomy

Clinical Scenario

Performed for symptomatic intramural leiomyoma causing significant bleeding.

Documentation Requirements

Operative report detailing the indication for surgery and findings.

Specialty Considerations

Obstetricians should document the patient's history and any pre-operative imaging.

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 data collection and reimbursement processes. D25.1 provides a clear distinction from other types of fibroids, facilitating better patient management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of leiomyomas, improving the accuracy of data collection and reimbursement processes. D25.1 provides a clear distinction from other types of fibroids, facilitating better patient management and research.

Reimbursement & Billing Impact

reimbursement processes. D25.1 provides a clear distinction from other types of fibroids, facilitating better patient management and research.

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 intramural leiomyoma?

Common symptoms include heavy menstrual bleeding, pelvic pain, and pressure symptoms affecting the bladder or bowel. Some women may be asymptomatic.