CPT Code for Endometrial Biopsy: A Complete and Comprehensive Guide in 2023

CPT Code for Endometrial Biopsy

Are you searching for the correct CPT code for endometrial biopsy procedures? Understanding the appropriate coding is crucial for accurate billing and reimbursement. In this article, we will provide you with a comprehensive guide on CPT codes for endometrial biopsy, helping you navigate the coding process with confidence. Gain insights and ensure compliant billing practices in this informative resource.

What is an Endometrial Biopsy

An endometrial biopsy is a procedure that involves taking a small sample of tissue from the lining of the uterus (endometrium) for examination under a microscope. It is usually done to diagnose abnormal uterine bleeding, infertility, or endometrial cancer.

CPT Code for Endometrial Biopsy

An endometrial biopsy can be performed in different ways, depending on the method used to obtain the tissue sample and whether it is done alone or with other procedures. The most common methods are:

Endometrial sampling (biopsy):

This is done by inserting a thin plastic catheter through the cervix and into the uterus and using suction to remove a small amount of endometrial tissue. This can be done in the office setting without anesthesia and takes only a few minutes. The CPT code for this procedure is 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy] without cervical dilation any method [separate procedure]).

Hysteroscopy with endometrial sampling (biopsy):

This is done by inserting a thin, lighted tube (hysteroscope) through the cervix and into the uterus, and using a small instrument to cut or scrape off a piece of endometrial tissue. This can be done in the office setting with local anesthesia, or in an outpatient facility with general anesthesia. The CPT code for this procedure is 58558 (Hysteroscopy surgical; with sampling [biopsy] of endometrium and/or polypectomy with or without D & C).

Dilation and curettage (D & C):

This is done by dilating the cervix and using a sharp instrument (curette) to scrape off the entire lining of the uterus. This is usually done in an outpatient facility with general anesthesia and takes about 15 minutes. The CPT code for this procedure is 58120 (Dilation and curettage any method [separate procedure]).

The choice of method depends on several factors, such as the reason for the biopsy, the patient’s medical history, the availability of equipment and facilities, and the physician’s preference.

Indications for Endometrial Biopsy:

  1. Abnormal uterine bleeding: When a patient experiences irregular or heavy menstrual bleeding.
  2. Evaluation of postmenopausal bleeding: To investigate the cause of bleeding occurring after menopause.
  3. Infertility evaluation: Assessing the endometrial lining to determine any factors contributing to infertility.
  4. Suspicion of endometrial cancer: When there are symptoms or risk factors that raise concerns about endometrial cancer.
  5. Suspected endometrial hyperplasia: To confirm the presence of abnormal thickening of the endometrium.
  6. Monitoring hormone therapy: Checking the response of the endometrium to hormone therapy.
  7. Evaluation of polyps or fibroids: Assessing the presence of growths or tumors in the endometrium.

Contraindications for Endometrial Biopsy:

  1. Pregnancy: Endometrial biopsy is generally avoided during pregnancy to prevent potential harm to the developing fetus.
  2. Active pelvic infection: In the presence of an active infection in the pelvic area, endometrial biopsy may be deferred until the infection is resolved.
  3. Known or suspected uterine perforation: If there is a concern about a perforation in the uterus, an endometrial biopsy may be contraindicated to avoid further injury or complications.
  4. Uncooperative patient or inability to tolerate the procedure: In cases where the patient is unable to cooperate or tolerate the procedure due to medical or psychological reasons, endometrial biopsy may be deferred or alternative methods may be considered.

Coding Tips and Guidelines

When coding for an endometrial biopsy, it is important to follow these tips and guidelines:

  • Use the appropriate CPT code based on the method used to obtain the tissue sample, and whether it is done alone or with other procedures.
  • Use modifier –59 (Distinct procedural service) if the endometrial biopsy is done separately from another procedure on the same day, such as a colposcopy or a laparoscopy.
  • Use modifier –22 (Unusual procedural services) if the endometrial biopsy involves a significant amount of work or complexity that is not reflected by the usual CPT code. For example, if the patient has cervical stenosis that requires cervical dilation before the biopsy, or if the biopsy is done for ovarian cancer staging. In this case, you should also document the reason for using modifier –22 and provide supporting evidence.
  • Link the CPT code to the appropriate ICD-10-CM code that indicates the reason for performing the biopsy. For example, if the biopsy is done for abnormal uterine bleeding, use N92.4 (Excessive bleeding in the premenopausal period), or if it is done for endometrial cancer screening, use Z12.72 (Encounter for screening for malignant neoplasm of genital organs).
  • Check with your payer’s policies and guidelines for any specific requirements or limitations on coding and reimbursement for endometrial biopsies.

Conclusion

An endometrial biopsy is a common procedure that can provide valuable information about the health of the uterus and its lining. Coding for this procedure can be straightforward if you follow the tips and guidelines. However, you should always verify your coding with your payer’s policies and guidelines before submitting your claims.

I hope this blog post helps you understand an endometrial biopsy and how to code it correctly. If you have any questions or feedback, please leave a comment below. Thank you for reading! 😊

References

(1) Ob-Gyn | ABCs of Biopsies A Diagnostic Coding Primer – AAPC.
(2) Endometrial Biopsy CPT Code (2022) Description, Guidelines ….
(3) Endometrial Biopsy CPT Code – PeekaPoo – S.

FAQs: CPT Code for Endometrial Biopsy

Q1: What is the CPT code for endometrial biopsy?

A1: The CPT code for endometrial biopsy is 58100, which covers endometrial sampling (biopsy) with or without endocervical sampling (biopsy) without cervical dilation.

Q2: Is there a specific modifier required for endometrial biopsy coding?

A2: Generally, a modifier is not required for endometrial biopsy coding. However, consult payer policies and guidelines to ensure specific requirements.

Q3: Can an endometrial biopsy be performed in the office setting?

A3: Yes, an endometrial biopsy can be performed in the office setting without anesthesia. It is a relatively quick procedure.

Q4: What other procedures can be performed in conjunction with an endometrial biopsy?

A4: Other procedures that can be performed with an endometrial biopsy include colposcopy, hysteroscopy, and dilation and curettage (D&C).

Q5: How do I choose the appropriate CPT code for an endometrial biopsy performed with additional procedures?

A5: Select the primary procedure’s CPT code based on the main focus of the overall procedure, and use additional codes for any ancillary procedures performed.

Q6: Are there specific ICD-10-CM codes to link with the CPT code for endometrial biopsy?

A6: Yes, it is important to link the relevant ICD-10-CM code that reflects the reason for the endometrial biopsy, such as abnormal uterine bleeding or suspected endometrial cancer.

Q7: What should I do if I have questions about coding or reimbursement for endometrial biopsy?

A7: For specific coding or reimbursement questions, it is best to consult coding experts, or professional organizations, or review payer policies for accurate and up-to-date information.

CPT Code for Endometrial Biopsy: A Complete and Comprehensive Guide in 2023
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