Uterine fibroids—also known as leiomyomas—are non‑cancerous masses that develop in or around the uterus. They affect a significant number of women, causing symptoms ranging from mild discomfort to severe menstrual bleeding and reproductive challenges. Proper coding with ICD‑10 ensures accurate documentation, seamless billing, and optimal management of care.
In this comprehensive guide, we dive deep into the ICD‑10 codes for uterine fibroids, their subtypes, clinical considerations, and how Meister Surgical instruments support diagnostic and therapeutic procedures in fibroid management.
🧠 What Are Uterine Fibroids?
Also called leiomyomas, uterine fibroids are benign smooth‑muscle tumors arising from the uterus. Although typically non‑malignant, they can lead to:
- Heavy menstrual bleeding (menorrhagia)
- Pelvic pain, pressure, or bloating
- Reproductive issues (infertility, miscarriage)
- Frequent urination or constipation (if large)
Types by Location:
- Intramural – within the uterine wall
- Submucosal – projecting into the uterine cavity
- Subserosal – extending outward
- Pedunculated – attached by a stalk internally or externally
Management ranges from watchful waiting to medical therapy, and surgical interventions like myomectomy or hysterectomy—procedures often performed using specialized tools from Meister Surgical.
ICD‑10 Codes for Uterine Fibroids
The appropriate ICD‑10 code depends on fibroid location and associated symptoms or complications.
Primary Code Category:
D25 – Leiomyoma of the uterus
Breakdown:
- D25.0: Intramural fibroid
- D25.1: Submucosal fibroid
- D25.2: Subserosal fibroid
- D25.9: Leiomyoma of uterus, unspecified
Always assign codes to capture associated conditions, such as:
- N92.0 – Excessive and frequent menstruation
- N93.9 – Abnormal uterine hemorrhage, unspecified
- N85.811 – Fibroid of the cervix (if cervical fibroid)
Example combinations:
A patient with submucosal fibroid and heavy bleeding should be coded:
- D25.1 – Submucosal fibroid
- N92.0 – Excessive menstrual bleeding
Accurate coding ensures both clinical clarity and billing compliance.
Diagnosing and Documenting Uterine Fibroids
Proper coding begins with thorough clinical documentation. Typically, diagnosis involves:
- Medical history: Symptoms like heavy bleeding, pain, fertility issues
- Physical exam: Palpable uterine enlargement
- Imaging: Ultrasound, MRI, or CT for detailed fibroid characterization
- Pathology: Histological confirmation post-surgery
Well-documented imaging findings—detailing size, number, and exact location—support accurate ICD‑10 coding and strengthen medical necessity for procedural interventions.
Treatment Options and Their ICD‑10 Implications
Treatment depends on symptom severity, age, fertility goals, and fibroid characteristics:
- Medical Management: GnRH agonists, contraceptives—typically no additional ICD‑10 codes unless side effects
- Minimally Invasive Procedures:
- Uterine artery embolization (UAE) – use codes for embolization (e.g., 37243)
- Endometrial ablation – CPT code 58563; ICD‑10 may include N92.0 alongside fibroid code
- Surgical Treatment:
- Myomectomy – CPT varies (e.g., 58140–58146); ICD‑10 code D25.x
- Hysterectomy – CPT 58150–58294; ICD‑10 includes D25.x + Z90.710 (absence of uterus)
Post-surgical documentation should reflect both the fibroid and the surgical procedure.
Role of Meister Surgical Instruments
Effective management—surgical or minimally invasive—relies on precision and high-quality instruments. Meister Surgical supplies tools essential for fibroid treatment:
| Instrument | Use |
|---|---|
| Tenaculum forceps | Cervical stabilization during myomectomy/hysteroscopy |
| Dilators and speculums | Access through cervical canal |
| Myoma screws & clamps | Grasping and manipulating fibroid tissue |
| Scissors (Metzenbaum, Mayo) | Tissue dissection during fibroid removal |
| Suction/irrigation sets | Maintaining clear visual field |
| Retractors (e.g., Senn, Richardson) | Exposure during open or laparoscopic surgery |
These instruments are crafted in surgical-grade stainless steel, adhering to ISO and CE-certified quality standards—providing reliability and safety during procedures.
Documentation & Coding: Best Practices
- Specify fibroid type and location – e.g., “D25.1 – Submucosal uterine fibroid.”
- Include symptom codes – N92.0 for heavy bleeding or N94.6 for dysmenorrhea.
- Record all procedures – Myomectomy, hysterectomy, ablation.
- Capture comorbidities – Anemia (D50.9), infertility (N97.x), or pregnancy complications (O34.x).
This ensures clarity in coding, supports medical justification, and minimizes audit risk.
Insurance Implications and Medical Necessity
Payor approval often relies on clear ICD-10 coding and documented symptoms. Common covered indications include:
- Prolonged, heavy menstrual bleeding
- Significant pain or bulk symptoms
- Reproductive dysfunction linked to fibroids
Including fibroid codes (D25.x) along with supporting diagnosis (N92.0, N94.6) strengthens prior-authorization requests and reimbursement outcomes.
Real-world Coding Scenarios
- 30-year-old woman with 5 cm submucosal fibroid causing heavy periods
- D25.1 – Submucosal uterine fibroid
- N92.0 – Excessive menstrual bleeding
→ Myomectomy CPT 58545
- 42-year-old with multiple fibroids, pelvic pressure, anemia
- D25.2 – Subserosal fibroid
- N92.0 – Heavy menstrual bleeding
- D50.9 – Anemia
→ Scheduled total abdominal hysterectomy
- Cervical fibroid discovered incidentally
- N85.811 – Fibroid of cervix
Coding for Post‑Surgical Outcomes
After treatment, new codes are required:
- Hysterectomy → Z90.710 – Acquired absence of uterus
- Document fibroid status and any residual disease
Outbound Resources for Clinicians & Coders
- AAPC resources on fibroid coding – provides best practices and current guidelines
- ACOG fibroid management guidelines – comprehensive clinical recommendations
These resources support accurate diagnosis, coding, and clinical decision-making.
Why Meister Surgical?
Meister Surgical is a trusted manufacturer of surgical tools worldwide. Our instruments offer:
- Superior quality: precision-engineered, corrosion-resistant
- Wide selection: designed for fibroid-focused procedures
- Available globally: fast shipping and bulk ordering
- Regulatory compliance: ISO 13485, CE certification
📩 Contact us for customized surgical trays or quotes: info@meistersurgical.com
Summary Table
| Topic | ICD‑10 Code(s) |
|---|---|
| Intramural fibroid | D25.0 |
| Submucosal fibroid | D25.1 |
| Subserosal fibroid | D25.2 |
| Unspecified fibroid | D25.9 |
| Cervical fibroid | N85.811 |
| Heavy menstrual bleeding | N92.0 |
| Abnormal uterine hemorrhage | N93.9 |
| Dysmenorrhea | N94.6 |
| Anemia, unspecified | D50.9 |
| Absence of uterus (post-op) | Z90.710 |
Final Thoughts
Accurate coding of uterine fibroids is essential for seamless clinical care, billing, and reporting. By pairing documentation excellence with high-quality surgical instruments from Meister Surgical, clinicians can optimize both patient outcomes and operational efficiency.
For consultations or to explore our fibroid‑focused instruments, visit Meister Surgical or contact info@meistersurgical.com today.