Report CPT code 58100 if a provider took a tissue sample from the patient’s uterus lining for endometrial biopsy without widening the cervix.
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.
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).”
TIP: You can find all the CPT codes for endometrial biopsy here.
The 58100 CPT code procedure begins after the provider determines the uterus position with a pelvic exam.
Then, they begin by asking the patient to position themself in the lithotomy position before they insert a speculum and, if necessary, inject the cervix with local anesthesia.
Next, the provider seizes the patient’s cervix with a tenaculum and takes a sample after the cervix is sterilized with an antiseptic. They use a curette or brush (Pipelle®) and send the sample to the laboratory for examination.
They then insert the brush or curette into the patient’s uterine cavity for a biopsy of the uterine lining.
Finally, they remove all instruments and end the procedure with checks for bleeding.
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.