endo bx with cervical dilation

missy874

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Please see the note below, if cervical dilation was performed, what CPT should I use. Provider wanted 58100, seems simple enough right??

Procedure: Endometrial Biopsy
Indication: abnormal uterine bleeding


Timeout performed to include confirming patient using 2 identifiers, procedure at 0837 o'clock. Procedure chaperoned by: xxxxx.


Pelvic exam performed determining position of the uterus. Speculum was placed and cervix and vaginal wall was cleansed with povidone iodine.
Tenaculum was applied.
Cervical dilator was used.
Pipelle was placed through the cervix to 8 cm and piston was withdrawn. Sample was collected with a rolling motion of the pipelle while simultaneously moving the sheath tip back and forth. Pipelle was removed and sample was collected in a formalin container which was sent to pathology.


Patient tolerated the procedure well. Aftercare instructions were provided. Will follow-up via phone once pathology results are reported.
 
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