Outpatient Facility Coding Alert

Question: 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 curettage? Both of these providers do this procedure without 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 it is an inherent component of 58120, noted by a “0” indicator under the National Correct Coding Initiative (CCI).