ICD-10 Code D25.2 | Subserosal leiomyoma of uterus Symptoms, Diagnosis, Billing

Subserosal leiomyoma of the uterus is a benign tumor that arises from the smooth muscle layer of the uterus, specifically located beneath the serosal surface. These tumors can cause symptoms such as pelvic pain, pressure, and abnormal bleeding. Accurate coding with ICD-10 Code D25.2 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and treat this condition.

What is ICD-10 Code D25.2 for Subserosal leiomyoma of uterus?

ICD-10 Code D25.2 specifically identifies subserosal leiomyoma of the uterus, which are fibroids located on the outer surface of the uterine wall. This code is used when documenting cases of subserosal fibroids that may lead to complications such as pain or pressure symptoms. It is crucial for accurate clinical documentation and billing, particularly when these tumors require surgical intervention or monitoring.

ICD-10 Code D25.2 – Clinical Definition and Explanation of Subserosal leiomyoma of uterus

Subserosal leiomyomas are non-cancerous growths that develop on the outer layer of the uterus. They are often asymptomatic but can lead to significant discomfort and complications if they grow large enough. Medical attention is necessary to evaluate symptoms and determine appropriate management strategies.

Key Clinical Features:

• May cause pelvic pain or pressure
• Can lead to urinary frequency or urgency
• Associated with abnormal uterine bleeding
• Often discovered incidentally during imaging studies

ICD-10 Code D25.2 for Subserosal leiomyoma of uterus – SOAP Notes & Clinical Use

ICD-10 Code D25.2 is utilized in SOAP notes to document the presence of subserosal leiomyomas, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code D25.2 for Subserosal leiomyoma of uterus Mean in SOAP Notes?

In SOAP notes, ICD-10 Code D25.2 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of subserosal leiomyoma. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.

Treatment Options for ICD-10 Code D25.2 – Subserosal leiomyoma of uterus

Management of subserosal leiomyomas may require hospitalization if complications arise. Treatment options vary based on symptom severity and patient preference.

Antibiotic Therapy:

• Not applicable as subserosal leiomyomas are not infectious

Supportive Care:

• Pain management with NSAIDs
• Monitoring for changes in symptoms
• Counseling on lifestyle modifications

Infection Control:

• Not applicable as subserosal leiomyomas are not infectious

How to Document Symptoms of Subserosal leiomyoma of uterus (ICD-10 D25.2) in SOAP Notes

Subjective:

• Patient reports pelvic pain that worsens with activity
• Experiencing increased urinary frequency
• Reports heavy menstrual bleeding
• No history of previous surgeries for fibroids

Objective:

• Abdominal examination reveals a palpable mass
• Ultrasound shows a subserosal leiomyoma
• Vital signs stable
• No signs of acute distress

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SOAP Note Guidelines for Diagnosing Subserosal leiomyoma of uterus (ICD-10 Code D25.2)

Assessment:

• Diagnosis: Subserosal leiomyoma of uterus, moderate severity
• ICD-10 Code: D25.2
• Contributing factors: Hormonal influences, family history of fibroids
• Symptoms consistent with diagnosis.

Plan:

• Consider referral to gynecology for further evaluation
• Discuss potential surgical options if symptoms persist
• Educate patient on monitoring symptoms
• Schedule follow-up in 6 months to reassess

Treatment & Plan Section for ICD-10 Code D25.2 – Subserosal leiomyoma of uterus

• Consider hormonal therapy to manage symptoms
• Discuss surgical options such as myomectomy if indicated
• Encourage regular follow-up and monitoring of symptoms
• Educate on lifestyle modifications to alleviate discomfort

Using ICD-10 Code D25.2 for Subserosal leiomyoma of uterus in Billing & SOAP Note Compliance

• Ensure accurate documentation of symptoms and clinical findings
• Use D25.2 in conjunction with relevant CPT codes for procedures
• Maintain clear records of patient education and follow-up plans
• Align treatment plans with clinical guidelines for justified billing

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

• D25.0 – Intramural leiomyoma of uterus
• D25.1 – Submucosal leiomyoma of uterus
• D25.9 – Leiomyoma of uterus, unspecified

ICD-10 Code D25.2 in Medical Billing and Insurance for Subserosal leiomyoma of uterus

ICD-10 Code D25.2 is critical for accurate billing in hospital and outpatient settings, particularly for gynecological care.

Billing Notes:

• Document all relevant patient history and symptoms clearly
• Use D25.2 in conjunction with procedure codes for surgical interventions
• Ensure compliance with payer guidelines for documentation
• Maintain accurate records to support claims

Common CPT Pairings: