CPT Code 58100: Endometrial Biopsy, Without Dilation

What is CPT code 58100?

CPT code 58100 describes an endometrial biopsy procedure performed without cervical dilation. This common gynecological procedure involves collecting a small sample of endometrial tissue from the lining of the uterus (endometrium) for laboratory examination. The endometrial sampling biopsy is typically performed to evaluate abnormal uterine bleeding, investigate postmenopausal bleeding, or screen for endometrial cancer.

During the procedure, a healthcare provider inserts a thin, flexible tube or specialized biopsy forceps through the cervical canal into the uterus to obtain endometrial tissue samples. Since CPT 58100 specifically designates "without dilation," this code applies when the cervix is not dilated during the sampling process. The procedure is typically performed in a doctor's office or outpatient setting and does not require anesthesia beyond local applications.

Endometrial biopsy helps identify various uterine conditions through microscopic examination of the tissue sample. Common clinical indications include:

• Investigation of abnormal uterine bleeding patterns
• Evaluation of postmenopausal bleeding
• Screening for endometrial cancer in high-risk patients
• Assessment of endometrial development for fertility evaluation
• Follow-up for previously diagnosed endometrial conditions

The physician may use various instruments such as a Pipelle sampler, an endocell device, or a Novak curette. Each of these instruments allows for the collection of endometrial tissue through gentle suction or scraping of the uterine lining. The entire procedure typically takes 5-10 minutes to complete. The tissue samples are then sent to the lab for pathological examination.

CPT code 58100 documentation requirements

Proper documentation for an endometrial biopsy without dilation (CPT 58100) requires comprehensive clinical notes that justify medical necessity and describe the procedure in detail. Documentation serves both clinical and reimbursement purposes, ensuring appropriate patient management and accurate billing.

A complete medical record for an endometrial biopsy should include:

• Detailed reason for performing the endometrial sampling (medical necessity)
• Patient's relevant gynecological history and current symptoms
• Pre-procedure evaluation, including physical examination findings
• Description of the procedure, specifying that it was performed without cervical dilation
• Notation of any complications or patient discomfort during the procedure
• Disposition of the endometrial tissue sample
• Post-procedure instructions provided to the patient
• Follow-up plan based on anticipated results

When documenting an endometrial biopsy, it's important to note if the procedure occurs as a separate procedure or in conjunction with other gynecologic services during the same encounter. This distinction affects billing and reimbursement.

If endocervical sampling or endocervical biopsy is performed alongside the endometrial biopsy, this should be documented as a separate procedure with its own medical justification. For patients with cervical stenosis where entry was difficult but dilation was not performed, document the challenging access without using terminology suggesting dilation was performed.

CPT code 58100 billing guidelines

Understanding the proper billing guidelines for CPT code 58100 is essential for accurate reimbursement and compliance with coding regulations. These guidelines address various aspects, including appropriate use of modifiers and billing restrictions.

The National Correct Coding Initiative (NCCI) includes several edits related to CPT 58100 that affect billing practices:

• Endometrial biopsy (58100) is often bundled with more comprehensive procedures like dilation and curettage (D&C)
• Cannot typically be billed on the same day as a complete hysteroscopy
• May not be reported separately when performed as part of a more extensive procedure
• Cannot be billed with certain evaluation and management services without appropriate modifiers

Other relevant codes

Related procedural codes that may be considered when coding for endometrial sampling procedures include:

• 58110: Endometrial sampling (biopsy) performed in conjunction with colposcopy (add-on code)
• 57505: Endocervical curettage (separate procedure)
• 57421: Colposcopy of the entire vagina with cervix; with biopsy(s) of vagina/cervix
• 58558: Hysteroscopy with sampling (biopsy) of endometrium and/or polypectomy; with or without D&C
• 59000: Amniocentesis; diagnostic
• 58120: Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)