CPT Code 58100 | Description & Clinical Information
CPT 58100 describes the procedure in which the provider obtains a tissue sample from the uterus lining for an endometrial biopsy without dilating the cervix, and may also perform an endocervical biopsy.
1. What Is CPT Code 58100?
CPT 58100 can be billed for an endometrial biopsy on a tissue sample from the patient’s uterus lining.
The provider does not widen the cervix while taking the tissue sample and can perform an endocervical biopsy simultaneously.
2. Description
The CPT book defines the 58100 CPT codes as: “Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure).”
3. Procedure
The procedure described by CPT code 58100 is a common technique used by medical providers to collect samples of cervical and uterine tissues for laboratory analysis. This procedure is usually performed in an outpatient setting and may be done for various reasons, including the diagnosis of abnormal uterine bleeding, monitoring of infertility, and detection of uterine cancer.
Before initiating the procedure, the healthcare provider will conduct a pelvic exam to determine the position of the uterus. Once the patient is in the lithotomy position, the provider inserts a speculum into the vagina, which allows them to visualize the cervix. To make the procedure more comfortable for the patient, the provider may also inject a local anesthetic into the cervix.
After the cervix has been cleaned with an antiseptic solution, the provider grasps the cervix with a tenaculum, a small instrument that helps to stabilize it. The provider then takes a small sample of cells from the cervix using a brush, Pipelle, or curette, depending on their preference. The sample is then sent to the laboratory for further analysis, which may take a few days or weeks.
After taking the sample from the cervix, the provider then inserts the instrument into the uterine cavity through the cervix and takes a sample of the uterine lining. This process is known as a uterine biopsy, and it helps to identify any abnormalities or changes in the endometrial tissues. The biopsy may cause some mild discomfort, but the procedure typically takes only a few minutes to complete.
Once the sampling is completed, the provider removes the instruments and checks for any signs of bleeding. If there is bleeding, they may apply pressure to the affected area to control it. Patients may experience some cramping or spotting after the procedure, but these symptoms generally subside within a few hours.
4. How To Use CPT Code 58100
You can use CPT 58110 if the provider performs an endometrial biopsy with colposcopy.
Do not use CPT code 58100 if the provider dilated the cervix during the procedure. You can bill CPT 58120 instead.
Report CPT code 57505 for endocervical curettage.
Return to all the CPT codes for endometrial sampling, d&c and uterus tumor excision procedures.
5. Resources
https://www.ncbi.nlm.nih.gov/books/NBK541135/
