Revenue Cycle Insider

Question: I have a report for an endometrial biopsy (EMB) that required cervical dilation due to cervical stenosis. What procedure code should I assign?

Texas Subscriber

Answer: You will assign 58120 (Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)) to report the procedure. While 58100 (Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)) mentions endometrial sampling via biopsy, the code also specifies that the procedure is performed without cervical dilation.

According to CPT^® Assistant, Volume 31, Issue 10, you’ll report 58120 when “uterine cervical stenosis is obstructing the passage of the endometrial sampling instrument and limiting access to the uterine cavity, thus necessitating dilatation of the cervical canal.” Make sure the medical record supports the need to dilate the cervical canal to back up the claim.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC