Intramural leiomyoma of the uterus is a benign tumor arising from the smooth muscle layer of the uterine wall. These tumors can cause symptoms such as heavy menstrual bleeding, pelvic pain, and pressure symptoms. Accurate coding with ICD-10 Code D25.1 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that patients receive appropriate care and treatment.
What is ICD-10 Code D25.1 for Intramural leiomyoma of uterus?
ICD-10 Code D25.1 specifically identifies intramural leiomyoma of the uterus, which are non-cancerous growths located within the uterine wall. This code is used in clinical documentation and billing when a patient presents with symptoms related to these tumors, facilitating accurate diagnosis and treatment planning.
ICD-10 Code D25.1 – Clinical Definition and Explanation of Intramural leiomyoma of uterus
Intramural leiomyomas are the most common type of uterine fibroids, often resulting from hormonal influences and genetic predispositions. They can lead to significant morbidity, including abnormal uterine bleeding and reproductive issues, necessitating medical evaluation and intervention.
Key Clinical Features:
- Commonly asymptomatic but may cause heavy menstrual bleeding
- Can lead to pelvic pain and pressure symptoms
- May affect fertility and pregnancy outcomes
- Typically diagnosed via ultrasound or MRI
ICD-10 Code D25.1 for Intramural leiomyoma of uterus – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code D25.1 is utilized to document the presence of intramural leiomyoma, aiding in the assessment of symptoms, treatment plans, and follow-up care. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.
What Does ICD-10 Code D25.1 for Intramural leiomyoma of uterus Mean in SOAP Notes?
ICD-10 Code D25.1 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of intramural leiomyoma. This linkage is crucial for continuity of care, supporting accurate billing, and meeting EHR documentation standards.
Treatment Options for ICD-10 Code D25.1 – Intramural leiomyoma of uterus
Management of intramural leiomyoma may require hospitalization in cases of severe symptoms or complications. Treatment options focus on symptom relief and may include surgical intervention.
Antibiotic Therapy:
- Not applicable as intramural leiomyoma is not infectious
Supportive Care:
- Pain management with NSAIDs
- Hormonal therapy to regulate menstrual bleeding
- Monitoring for changes in size or symptoms
Infection Control:
- Not applicable as intramural leiomyoma is not infectious
How to Document Symptoms of Intramural leiomyoma of uterus (ICD-10 D25.1) in SOAP Notes
Subjective:
- Patient reports heavy menstrual bleeding
- Complains of pelvic pressure and discomfort
- History of irregular menstrual cycles
- No significant past medical history noted
Objective:
- Abdominal examination reveals tenderness
- Pelvic ultrasound shows a 3 cm intramural leiomyoma
- Vital signs stable
- No signs of acute distress
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SOAP Note Guidelines for Diagnosing Intramural leiomyoma of uterus (ICD-10 Code D25.1)
Assessment:
- Diagnosis: Intramural leiomyoma of uterus, moderate severity
- ICD-10 Code: D25.1
- Contributing factors: Hormonal imbalance, genetic predisposition
- Symptoms consistent with diagnosis
Plan:
- Consider hormonal therapy to manage symptoms
- Schedule follow-up ultrasound in 6 months
- Educate patient on signs of complications
- Discuss surgical options if symptoms persist
Treatment & Plan Section for ICD-10 Code D25.1 – Intramural leiomyoma of uterus
- First-line treatment includes hormonal therapy (e.g., GnRH agonists)
- Non-pharmacologic strategies include lifestyle modifications and dietary changes
- Monitoring through regular pelvic exams and imaging studies
- Follow-up appointments to assess symptom management and treatment efficacy
Using ICD-10 Code D25.1 for Intramural leiomyoma of uterus in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in SOAP notes
- Use D25.1 in conjunction with relevant CPT codes for procedures performed
- Maintain compliance with coding guidelines to support reimbursement
- Document treatment plans that align with clinical guidelines for justifiable billing
Related ICD-10 Codes Often Used with Intramural leiomyoma of uterus
- D25.0 – Subserosal leiomyoma of uterus
- D25.2 – Submucosal leiomyoma of uterus
- D25.9 – Leiomyoma of uterus, unspecified
ICD-10 Code D25.1 in Medical Billing and Insurance for Intramural leiomyoma of uterus
ICD-10 Code D25.1 is crucial in medical billing, particularly in hospital and outpatient settings, to ensure accurate claims processing.
Billing Notes:
- Document all relevant patient history and symptoms to support the diagnosis
- Use D25.1 in appropriate clinical settings to avoid claim denials
- Ensure that treatment plans are clearly outlined in the medical record
- Include any relevant imaging or lab results that support the diagnosis
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 58150 | Total abdominal hysterectomy, for benign disease |
| 58558 | Laparoscopic hysterectomy, for benign disease |
| 58180 | Endometrial ablation, for heavy menstrual bleeding |
Frequently Asked Questions
Common Questions About Using ICD-10 Code D25.1 for Intramural leiomyoma of uterus
What are the common symptoms of intramural leiomyoma?
Common symptoms include heavy menstrual bleeding, pelvic pain, and pressure symptoms. Some patients may also experience urinary frequency or difficulty, depending on the size and location of the fibroid.
How is intramural leiomyoma diagnosed?
Diagnosis is typically made through pelvic ultrasound or MRI, which can visualize the fibroid's size and location within the uterine wall.
What treatment options are available for intramural leiomyoma?
Treatment options include hormonal therapy to manage symptoms, surgical options such as myomectomy or hysterectomy, and monitoring for changes in symptoms or size.
Is intramural leiomyoma a serious condition?
While intramural leiomyoma is generally benign, it can lead to significant symptoms and complications, necessitating medical evaluation and potential treatment.
