Coding Corner: Endometrial Biopsy with Cervical Dilation | Mary J. Cunningham, MD

Mary J. Cunningham, MD

Office endometrial biopsy in a postmenopausal patient may be difficult due to cervical stenosis.  The code for endometrial biopsy (58100) specifies “without cervical dilation.” It may not be combined  with the code for cervical dilation (57800) because of a CCI edit.  The appropriate code to use when the cervix is dilated at the time of endometrial biopsy is 58120 (dilation and curettage).

You need to clearly document the reason that the cervical dilation was required as well as the reason for the endometrial sampling, for example cervical stenosis (N88.2) and post-menopausal bleeding (N95.0).  Be aware that there is a 10 day global period associated with 58120.

Mary J. Cunningham, MD is a gynecologic oncologist and Director of Gynecologic Oncology at Upstate Medical University in Syracuse, NY.