Ob-Gyn Coding Alert

Here’s how to distinguish fibroids from polyps.

When you’re coding procedures related to uterine fibroids, accuracy depends on understanding anatomy, surgical intent, and CPT^® bundling rules. The following tips will help you confidently code fibroid-related diagnoses and procedures without falling into common traps.

Tip 1: Start by Identifying if the Growth Is a Fibroid or Polyp

Before you ever select a procedure code, make sure you understand what type of growth the provider is treating.

Polyps are overgrowths of the endometrial lining. They are intracavitary and typically smaller and easier to remove. Fibroids, also called leiomyomas or myomas, arise from the smooth muscle of the uterus and are generally larger and more complex to treat.

Fibroids are classified by location, and this matters for diagnosis coding:

• You should code submucous fibroids that grow toward the uterine cavity with D25.0 (Submucous leiomyoma of uterus). 
• You should code intramural fibroids that grow within the uterine wall (myometrium) with D25.1 (Intramural leiomyoma of uterus). 
• You should code subserous fibroids that grow outward toward the abdominal cavity with D25.2 (Subserosal leiomyoma of uterus). 
• If the provider does not specify the location, you should assign D25.9 (Leiomyoma of uterus, unspecified).

If documentation is unclear and it is not obvious whether the growth is a polyp or a fibroid, wait for pathology before finalizing the diagnosis code. Pathology results often clarify the distinction.

Tip 2: Do Not Separately Code Fibroid Removal With a Hysterectomy

If the uterus is removed, the fibroids go with it. You should never separately report fibroid excision when the ob-gyn performs a hysterectomy.

In these cases, your coding focus should be on the type and extent of the hysterectomy, not on the fibroids themselves. The fibroids support medical necessity, but they do not generate a separate procedure code.

Example: If the provider performs a total abdominal hysterectomy for multiple symptomatic fibroids, you will report 58150 (Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)). You would not assign an additional myomectomy or fibroid excision code.

Tip 3: Remember That Hysteroscopy Can Be Used to Treat Fibroids

Fibroids are not always treated through open or laparoscopic surgery. Submucous (intracavitary) fibroids can often be treated hysteroscopically, particularly when fertility preservation is a goal.

When a provider removes fibroids hysteroscopically and pathology confirms leiomyoma, you should report 58561 (Hysteroscopy, surgical; with removal of leiomyomata).

However, be careful with bundling rules. Code 58561 is permanently bundled with 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C), and no modifier may be used to override the edit. Even if the provider performs a dilation and curettage at the same time, you should report only 58561 when the physician documents fibroid removal.

Tip 4: Use Myomectomy Codes Only When the Uterus Is Preserved

A myomectomy means the provider removes fibroids while leaving the uterus intact. These procedures are commonly chosen when the patient desires future fertility.

Your code selection depends on the surgical approach and the number or size of fibroids removed:

• You should choose open (abdominal) myomectomy codes from the 58140-58146 series.
• You should choose laparoscopic myomectomy codes from the 58545-58546 series.

Example: Suppose your ob-gyn removes five or more intramural fibroids via an abdominal approach. You should report 58146 (Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach) with the appropriate D25.- (Leiomyoma of uterus) diagnosis code based on location.

Do not confuse myomectomy with hysterectomy. If the uterus is removed, myomectomy codes do not apply.

Tip 5: Recognize When Your Ob-Gyn Uses Ablation or Embolization

Fibroids are not treated exclusively with hysterectomy, hysteroscopy, or myomectomy. You may also see ablation or embolization procedures.

For radiofrequency ablation of fibroids, your code depends on the approach:

• Report 58580 (Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency) for transcervical radiofrequency ablation, which includes intraoperative ultrasound guidance. 
• Report 58674 (Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency) for laparoscopic radiofrequency ablation, also inclusive of ultrasound guidance.
• For uterine fibroid embolization, the correct CPT^® code is 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction). This code represents vascular embolization for tumors and includes all radiological supervision and interpretation.

Final Coding Takeaway

When coding fibroid-related services, always slow down and confirm:

• What type of growth is being treated?
• Where is the fibroid located?
• Is the uterus removed or preserved?
• Which surgical approach did the physician use?
• Do bundling rules apply?

Accurate fibroid coding depends on anatomy, intent, and documentation, not just procedure titles. When you align those elements correctly, your coding will stand up to payer review and accurately reflect the care provided.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor