Find out what your fibroid diagnosis options are for both ICD-9 and ICD-10.
If you’re reporting uterine fibroid removal, you need to know two things:
- Where the fibroid was located, so you can choose the diagnosis code.
- What method the obgyn used to take care of the growth.
Simplify this complicated coding scenario by busting the following four myths.You’ll know where to look in both your ICD and CPT manuals before the fibroid report lands on your desk.
Don’t Confuse Fibroids With Polyps
Myth: Fibroids and polyps are essentially the same thing.
Reality: True, fibroids and polyps are both growths, but one occurs in the endometrial lining while the other occurs in the muscle.
Polyps are small growths on the surface of the uterine wall that are easy for the ob-gyn to remove. In other words, “they are an overgrowth of the endometrial lining,” says David Glassman, DO, FACOG, medical director of Biltmore Women’s Health and Aesthetics and assistant program director at the department of obstetrics and gynecology residency at Banner Good Samaritan in Phoenix. “They’re intracavitary lesions.”
Fibroids (or myomas) are larger and are usually imbedded in the smooth muscle of the uterine wall. “They are almost always benign, but in rare circumstances, they can become a sarcoma (muscle cancer),” Glassman says. These growths require more work to remove, hence the procedures associated with fibroids tend to have more relative value units (RVUs). They occur in three main locations:
- Submucous fibroids (218.0) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.
- Intramural fibroids (218.1) also called interstitial fibroids grow within the uterine wall (myometrium).
- Subserous fibroids (218.2) or subperitoneal fibroids grow outward from the uterine wall toward the abdominal cavity.
If the physician does not specify the location of the uterine fibroid, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.
Important: You should report these 218 fibroid codes based on size, location (the fourth digit), and number, Glassman says.
Sometimes, ob-gyns may have trouble distinguishing between a small fibroid and a large polyp, but “they do have different appearances and textures when visualized during the procedure,” Glassman says. If you don’t have enough to choose your ICD-9 code, you may need to wait for the pathology to return for a final diagnosis (a delay of 10 days or so).
Look ahead: Once payers start requiring ICD-10, your diagnosis codes will include numbers and letters. For example, ICD-10 2010 lists the previously mentioned fibroid codes as:
- D25.0 — Submucous leiomyoma of uterus
- D25.1 – Intramural leiomyoma of uterus or Interstitial leiomyoma of uterus
- D25.2 — Subserosal leiomyoma of uterus or Subperitoneal leiomyoma of uterus
- D25.9 — Leiomyoma of uterus, unspecified
Head to www.cdc.gov/nchs/icd/icd10cm.htm#10updateto learn more about ICD-10.
Examine Your Hysterectomy Options
Myth: If your ob-gyn removes a fibroid and the uterus entirely, then you should report both procedures.
Reality: You would not code the fibroid removal separately if the ob-gyn is removing the uterus. In other words, if the ob-gyn removes the uterus entirely, he performed a hysterectomy. In the process, he removed the accompanying fibroids attached to or inside the uterus.
Hysterectomy is the most common surgical treatment option, but only when the fibroids are causing problems, such as abdominal pain or heavy bleeding. Without removal of the uterus, recurrence of fibroids is common.
The code assignment will depend on the type and extent of the hysterectomy, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. For more information on this topic, register for her June 30 presentation.
Example: Because the patient is older than 50 years and has multiple fibroids, your ob-gyn performs a total abdominal hysterectomy (58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). You would not report an additional code for the fibroid removal.
Hem in Your Hysteroscopy Choices
Myth: Your ob-gyn won’t treat fibroids via a hysteroscopy.
Reality: An ob-gyn may treat a patient with fibroids with a hysteroscopy. Hysteroscopic submucous resection removes a portion of the protruding fibroid and preserves fertility.
The hysteroscopic procedure requires “the close monitoring of distention media, electrosurgical devices, as well as a patient’s anatomy to avoid perforating the uterus,” Glassman says. “Ob-gyns usually perform this straightforward approach for intracavitary (submucosal) fibroids.”
Example: Your ob-gyn removed polyps and fibroids by hysteroscope. The pathology diagnosis is fibroid. You should report 58561 (Hysteroscopy, surgical; with removal of leiomyomata) — unless the ob-gyn also performed a dilation and curettage (D&C). If the ob-gyn did, you can bill both 58561 and 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).
Master Myomectomy Codes
Myth: A myomectomy means the ob-gyn takes more than just the uterine fibroids.
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