# ob/gyn



## carla g (Oct 24, 2011)

I need some input on coding in office D&C.....Can cpt 58120 be used if the DR. does not use any anesthesia, local, etc? Or, can cpt 57800-59 be used for the dilation only and then 58100 be used for the biopsy?


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## Anastasia (Oct 25, 2011)

57800 and 58100 can't be billed together. I'd use 58120.


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## ajs (Oct 26, 2011)

Actually you are indicating two totally different procedures here.  

58120 is a Dilation & Curettage of the uterus usually done for bleeding, either to diagnose the cause or treat the problem. It can be done without anesthesia, but most of the time it is done outpatient at the hospital as it can be quite painful for some women.

58100 is an Endometrial Biopsy or a sample of tissue from the endometrium taken through the cervix, you can also take an endocervical sample at the same time, but generally dilation is not required as the instrument used is very thin and flexible and the sample is quite small.

So your answer is, if dilation was done and then curettage of the uterus to obtain the endometrial sample, then 58120 is correct.  

If the Endometrial Biopsy was done and some dilation to accomodate the instrument, then you would code 58100 and the dilation is considered included.

All depends on exactly what was documented in the notes.


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## mitchellde (Oct 26, 2011)

can POS be an 11 for 58120?  I was under the understanding this had to be a 22 or 21.


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## ajs (Oct 26, 2011)

mitchellde said:


> can POS be an 11 for 58120?  I was under the understanding this had to be a 22 or 21.



It can be done in office, many Gyn procedures are now done in an office setting so POS 11 is allowed.


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## carla g (Nov 2, 2011)

thanks so much for your help....thats exactly what I thought!


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