Biopsies are diagnostic procedures to obtain a tissue sample from the body in order to examine it. In interventional radiology, we have separate CPT codes for biopsy of different parts of the body. The most common and diverse coding is for Breast biopsy in Interventional radiology. However, we are here to learn how to find out CPT code for endometrial biopsy. Coding biopsy is very confusing while coding medical charts; we tend to code an open procedure code for a minimal invasive procedure. We face a similar situation for coding endometrial biopsy. We have different CPT code for endometrial biopsy (58100 & +58110), which we will learn here.
Separate CPT code for endometrial biopsy
Endometrial Biopsy extracts samples from the tissue lining (endometrium) the inside of the uterus. The samples are sent to pathology for more studying purpose. The sample of tissue is analyzed under a microscope in the laboratory by a pathologist, a doctor with special training in diagnosis of diseases based upon tissue examination.The most common reasons for performing an endometrial biopsy are abnormal uterine bleeding, amenorrhea and menopausal and postmenopausal disorders. The finally code 58100 is used for Endometrial biopsy which is a Separate procedure code.
58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy] without cervical dilation any method [separate procedure])
Related CPT code for Endometrial biopsy
+ 58110 Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure)
In this exam, a tool is used to grasp the cervix and pull it down. The physician places a curette in the endocervical canal and passes it into the uterus. The endometrial lining of the uterus is scraped in several places to obtain tissue for a biopsy sample. The endometrial sampling is performed in conjunction with direct visualization of the vagina and cervix and is reported in addition to the separately reportable primary colposcopy.
58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)
In this exam, the physician inserts a speculum into the vagina to view the cervix. A tool is used to grasp the cervix and pull it down. A dilator is inserted into the endocervix and through the cervical canal to enlarge the opening. The physician places a curette in the endocervical canal and passes it into the uterus. The endometrial lining of the uterus is scraped on all sides for diagnostic or therapeutic purposes.
Read also: When to use CPT code for Sleep study
Do and Don’t with CPT code for endometrial biopsy
Do not code 58100 for Endocervical curettage, use code 57505 if not done as part of dilation and curettage.
Use CPT code 58110 when endometrial biopsy is performed in conjunction with colposcopy. Use 58110 CPT code along with 57420, 57421, 57452-57461.
Women with endometriosis develop tissue that looks and acts like endometrial tissue outside of the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity.