Ob-Gyn Coding Alert

Question: My ob-gyn performed an endometrial biopsy (58100) and also noted dilation of cervix (57800) due to cervical stenosis. My understanding is that because CPT designates 57800 as a -separate procedure,- I cannot bill this code with 58100. If that is the case, then why does 58100 read, -... without cervical dilation-? Does this mean the ob-gyn may or may not perform cervical dilation with this code?

Nevada Subscriber

Answer: Your ob-gyn can certainly perform dilation when there is cervical stenosis, but you just won't get reimbursed if you report 57800 (Dilation of cervical canal, instrumental [separate procedure]) with 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]).

If the sampling requires cervical dilation, go with 58120-52 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]; reduced services) if the ob-gyn does not perform a complete curettage.