Ob-Gyn Coding Alert

Question: The Feb. 2012 issue of the Ob-gyn Coding Alert has an example of CPT® 58100-endometrial sampling (biopsy) as: “...plastic catheter into the uterus and suctions out a small amount of the endometrial lining.” Dilation is bundled with 58100. If a provider does some cervical dilation along with an endometrial sampling, at what point do we change from coding a 58100, 58120-52 or 58120? I spoke with a provider who uses the plastic catheter suction device and states he does a 360 degree endometrial curettage, after dilating the cervix slightly and sounding the uterus. Another provider uses the same tool and states he does a 360 degree endometrial biopsy, after sounding the uterus and dilating the cervix as needed. Is there a clear CPT® guideline on what is considered a sampling/biopsy and what is considered a curettage? Both of these providers do this procedure with out anesthesia for menorrhagia. 

Iowa Subscriber

Answer: You can use CPT® code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) for a complete or fractional D&C. 

Code 58100 (Endometrial sampling ([biopsy] with or without endocervical sampling ([biopsy)], without cervical dilation, any method ([separate procedure]) is intended to denote a procedure where a small section of tissue is removed for examination and no dilation of the cervix is required in the process. A physician who dilates the cervix and then does a complete 360 degree sampling of the uterus is performing what would be referred to as a “fractional” D&C, and the code 58120 would be the most appropriate code to use in this case. You cannot report code 58100 with the code for cervical dilation because when dilation is performed the most correct code would become 58120.