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December 13, 2004

Coding for Uterine Fibroids
For The Record
Vol. 16 No. 25 Page 50

Uterine fibroids are common noncancerous (benign) tumors of the uterus that typically appear during the childbearing years. Also called leiomyomas, myomas, or fibromyomas, uterine fibroids can range in size and grow slowly or rapidly. In addition, a patient may have only one fibroid or a cluster of several. Uterine fibroids are classified to ICD-9-CM category 218. The fourth-digit subcategory code identifies the location of the uterine fibroid:

• Submucous fibroids (218.0) grow from the uterine wall toward the uterine cavity.

• Intramural fibroids (218.1) grow within the uterine wall (myometrium). They are also called interstitial fibroids.

• Subserous fibroids (218.2) grow outward from the uterine wall toward the abdominal cavity. They are also called subperitoneal fibroids.

If the physician does not specify the location of the uterine fibroid, assign code 218.9.

Signs and Symptoms
In many cases, uterine fibroids are asymptomatic and are diagnosed during an annual pelvic exam or during prenatal care. However, if symptoms are present, they may include the following:

• Abnormal menstrual bleeding — heavier or more prolonged than normal

• Bleeding between periods

• Abdominal or lower back pain

• Pain during sexual intercourse

• Difficult or frequent urination

• Pelvic pressure

• Constipation

Other conditions with similar symptoms of heavy or abnormal bleeding include endometrial polyp (621.0), pelvic inflammatory disease (category 614), endometriosis (category 617), ectopic pregnancy (category 633), and endometrial cancer (182.0).

Diagnosis
Diagnosis of uterine fibroids may require:

• a pelvic exam to palpate fibroids;

• an ultrasound to evaluate the growth; and/or

• a hysteroscopy to examine the lining of the uterus and take biopsies if necessary to rule out endometrial cancer.

Complications
Because the patient has heavy or prolonged episodes of bleeding, anemia may result. Mild anemia can cause weakness and fatigue. Moderate or severe anemia can cause shortness of breath, rapid heart rate, lightheadedness, headaches, pale skin, and restless leg syndrome. The patient may be treated with iron supplements or blood transfusions. If the physician does not specify the type of anemia, assign code 285.9. However, if the physician relates the anemia to the heavy or prolonged bleeding, assign code 280.0 for chronic or unspecified blood loss anemia or code 285.1 for acute blood loss anemia. Specific code assignment is dependent on the physician’s documentation.

In rare instances, infertility may occur as a result of uterine fibroids due to difficulty of a fertilized egg to implant on the uterine lining. In addition, large uterine fibroids that press against the bladder may cause a urinary tract infection (599.0). As stated earlier, uterine fibroids are benign tumors. However, in extremely rare cases, a malignant change in a fibroid may occur, called leiomyosarcoma. The specific code assignment will depend on exact location of the fibroid.

Treatment
If the fibroid is asymptomatic, typically the treatment is the “wait-and-see” approach. No surgery or medications will be ordered, but diagnostic tests will continue to evaluate growth. If the fibroids are causing problems, the physician may try medications to control the symptoms.

Oral contraceptives may help control heavy menstrual bleeding, but they do not control fibroid growth. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to reduce heavy bleeding, pain, and inflammation. Common NSAIDs include aspirin, ibuprofen (Advil, Motrin, Rufen), and naproxen (Aleve, Anaprox, Naprosyn). Gonadotropin-releasing hormone (GnRH) agonists (Lupron, Viadur) may shrink fibroids by reducing the amount of estrogen in the body. Danazol (Danocrine) suppresses estrogen and is effective for controlling heavy menstrual bleeding caused by fibroids. Finally, mifepristone (RU486), which is under investigation for the treatment of uterine fibroids, is an antiprogestin that may reduce fibroids. Long-term use of some of the above medications may cause serious side effects. Therefore, the medications are used temporarily in preparation of menopause or surgery.

Surgery may be necessary in the treatment of fibroids. Some of the common surgical procedures performed include the following:

• Myomectomy (68.29) — the removal of uterine fibroids only, which preserves fertility.

• Endometrial ablation (68.23) — laser surgery, which may be done through a hysteroscope, to remove fibroids.

• Hysteroscopic submucous resection (68.29) — removes a portion of the protruding fibroid and preserves fertility.

• Hysterectomy — removal of the uterus. This is the most common option but only when the fibroids are causing problems. The code assignment will depend on the type and extent of hysterectomy performed. Without removal of the uterus, recurrence of fibroids is common.

If the fibroid surgery was performed via a hysteroscope or laparoscope, code 68.12 or 54.21 should not be assigned as an additional code. Only the procedure performed should be coded and not the approach (AHA Coding Clinic for ICD-9-CM, 1992, third quarter, page 12).

Uterine fibroid embolization, or uterine artery embolization (99.29), is a nonsurgical minimally invasive procedure that will shrink the fibroids by cutting off the blood supply. A catheter is inserted through an artery in the leg to the arteries in the uterus. Tiny particles of plastic or gelatin are then inserted through the arteries to block the blood flow inside the fibroids. Without blood flow, the fibroids shrink or may even disappear over time. This procedure may require an overnight hospital stay (AHA Coding Clinic for ICD-9-CM, 1999, third quarter, page 21).

Coding and sequencing for uterine fibroids are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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