Surgery: Female Genital System

 CPT Assistant, October 2021, Volume 31, Issue 10, page 14

Question:

What is the appropriate CPT code to report when cervical dilation is necessary to access the uterine cavity to obtain a uterine biopsy due to cervical stenosis?

Answer:

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, code 58120, Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical), would be reported. When cervical dilation is performed, the medical record should contain supporting documentation for the necessity of the dilation procedure. Code 58100, Endometrial sampling (biopsy), with or without endocervical sampling (biopsy) without cervical dilation, any method (separate procedure), would be reported for endometrial sampling without dilation.