ICD-10 Code D25.0 | Submucous leiomyoma of uterus Symptoms, Diagnosis, Billing

Submucous leiomyoma of the uterus is a benign tumor arising from the smooth muscle layer of the uterus, specifically located beneath the endometrial lining. These tumors can cause significant clinical symptoms, including abnormal uterine bleeding, pelvic pain, and reproductive issues. Accurate coding with ICD-10 Code D25.0 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and resources.

What is ICD-10 Code D25.0 for Submucous leiomyoma of uterus?

ICD-10 Code D25.0 represents submucous leiomyoma of the uterus, a type of fibroid that grows into the uterine cavity. This condition can lead to complications such as heavy menstrual bleeding and infertility. The code should be used in clinical documentation and billing when a patient presents with symptoms related to this specific type of leiomyoma, ensuring accurate representation of the patient's diagnosis.

ICD-10 Code D25.0 – Clinical Definition and Explanation of Submucous leiomyoma of uterus

Submucous leiomyomas are benign tumors that develop from the smooth muscle of the uterus and protrude into the uterine cavity. They can cause various symptoms and may require medical intervention. Understanding this condition is crucial for effective management and treatment.

Key Clinical Features:

• Commonly presents with heavy menstrual bleeding (menorrhagia).
• May cause pelvic pain or pressure symptoms.
• Can lead to infertility or complications during pregnancy.
• Typically diagnosed via ultrasound or hysteroscopy.

ICD-10 Code D25.0 for Submucous leiomyoma of uterus – SOAP Notes & Clinical Use

ICD-10 Code D25.0 is utilized in SOAP notes to document the presence of submucous leiomyoma of the uterus. It plays a critical role in capturing patient symptoms, assessment findings, and treatment plans, relevant in both acute and chronic care settings.

What Does ICD-10 Code D25.0 for Submucous leiomyoma of uterus Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D25.0 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of submucous leiomyoma. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D25.0 – Submucous leiomyoma of uterus

Management of submucous leiomyoma may require hospitalization, especially if symptoms are severe. Treatment options focus on symptom relief and may include surgical intervention.

Antibiotic Therapy:

• Not applicable as submucous leiomyoma is not an infectious condition.

Supportive Care:

• Pain management with NSAIDs.
• Hormonal therapy to regulate menstrual bleeding.
• Monitoring for changes in symptoms.

Infection Control:

• Not applicable as this condition is not infectious.

How to Document Symptoms of Submucous leiomyoma of uterus (ICD-10 D25.0) in SOAP Notes

Subjective:

• Patient reports heavy menstrual bleeding for the past three months.
• Experiences pelvic pain that worsens during menstruation.
• History of infertility with no previous pregnancies.
• Reports increased urinary frequency.

Objective:

• Abdominal examination reveals tenderness in the lower abdomen.
• Pelvic ultrasound shows a submucous leiomyoma measuring 3 cm.
• Vital signs stable; no signs of acute distress.
• Hemoglobin level indicates mild anemia.

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SOAP Note Guidelines for Diagnosing Submucous leiomyoma of uterus (ICD-10 Code D25.0)

Assessment:

• Diagnosis: Submucous leiomyoma of uterus, moderate severity.
• ICD-10 Code: D25.0.
• Contributing factors: Heavy menstrual bleeding and pelvic pain.
• Consideration for surgical intervention based on symptom severity.

Plan:

• Pharmacologic treatment: Initiate hormonal therapy to manage bleeding.
• Patient education on symptom tracking and management.
• Monitoring: Schedule follow-up ultrasound in three months.
• Referral to gynecology for potential surgical evaluation.

Treatment & Plan Section for ICD-10 Code D25.0 – Submucous leiomyoma of uterus

• First-line pharmacologic treatment includes hormonal therapy (e.g., progestins).
• Non-pharmacologic strategies include lifestyle modifications and dietary changes.
• Monitoring practices involve regular follow-up ultrasounds to assess tumor growth.
• Patient education on recognizing symptoms that require immediate medical attention.

Using ICD-10 Code D25.0 for Submucous leiomyoma of uterus in Billing & SOAP Note Compliance

• Select appropriate ICD-10 code based on clinical findings and documentation.
• Ensure clear documentation of symptoms under Subjective (S) and Objective (O) sections.
• Align treatment plans with clinical guidelines to support justified billing.
• Include relevant CPT codes that correspond to diagnostic and therapeutic procedures.

Related ICD-10 Codes Often Used with Submucous leiomyoma of uterus

• D25.1 – Intramural leiomyoma of uterus
• D25.2 – Subserosal leiomyoma of uterus
• D25.9 – Leiomyoma of uterus, unspecified

ICD-10 Code D25.0 in Medical Billing and Insurance for Submucous leiomyoma of uterus

ICD-10 Code D25.0 is crucial for accurate billing in hospital, ER, or outpatient settings, ensuring proper reimbursement for services rendered.

Billing Notes:

• Document all relevant patient history and clinical findings to support the diagnosis.
• Use the code in conjunction with appropriate CPT codes for procedures performed.
• Ensure compliance with payer-specific guidelines for coding and billing.
• Review documentation for completeness before submitting claims.

Common CPT Pairings: