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CPT Code 58100 Endometrial Sampling, D&C and Uterus Tumor Excision Procedures

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Accurate coding for gynecologic diagnostic procedures is critical to ensure proper reimbursement and regulatory compliance. CPT 58100 is used to report endometrial sampling (biopsy) without cervical dilation, a common procedure performed in the OBGYN setting to evaluate abnormal uterine bleeding, infertility, or suspected endometrial pathology.

This guide explains the 2025 AAPC and CMS updates for CPT 58100, outlining clinical indications, documentation requirements, modifier use, and reimbursement data to help OBGYN providers code confidently and compliantly.

CPT 58100 – Description

Official Definition: “Biopsy of the uterus lining (endometrium) performed without cervical dilation.”

This procedure involves inserting a sampling device (such as a Pipelle or Novak curette) into the uterine cavity through the cervical canal to obtain endometrial tissue. The sample is then sent to pathology for histologic examination.

Key details:

  • Diagnostic procedure - not therapeutic.
  • Performed without cervical dilation (if dilation is performed, use CPT 58110).
  • May be conducted in-office under minimal anesthesia.
  • Commonly used to assess hormonal response, malignancy, or uterine abnormalities.

When to Use CPT 58100

CPT 58100 should be reported when an OBGYN performs a diagnostic endometrial biopsy to evaluate uterine pathology.

Typical clinical indications include:

  • Abnormal or postmenopausal uterine bleeding.
  • Endometrial hyperplasia or suspected carcinoma.
  • Infertility evaluation (luteal phase assessment).
  • Follow-up for abnormal ultrasound findings (thickened endometrium).
  • Monitoring after hormone therapy or tamoxifen use.

Do not report CPT 58100 for:

  • Biopsy with dilation and curettage (use CPT 58110).
  • Removal of intrauterine devices (use CPT 58301).
  • Therapeutic endometrial ablation (use 58353 or 58563).

Coding Guidelines and Compliance

Following AAPC and CMS 2025 coding guidance:

  • Report 58100 once per session, even if multiple samples are obtained.
  • The procedure includes specimen collection and handling but not pathology interpretation.
  • If performed with colposcopy or cervical biopsy, apply appropriate modifiers to avoid bundling denials.
  • CPT 58100 carries a 10-day global period, and routine follow-up visits within this time are bundled.
  • Ensure medical necessity is supported by documented symptoms or abnormal findings.

Reimbursement Overview

CPT 58100 – 2025 Payment Data

  • Global period: 10 days
  • Typical setting: Physician office or outpatient facility
  • Average Medicare reimbursement: ~$100 – $125 (location-dependent)
  • ASC rate: Typically bundled under minor gynecologic procedures

Commercial payers may request pathology confirmation or abnormal imaging reports to justify medical necessity. Proper linkage of diagnosis codes (e.g., N93.9, N95.0, N85.00) is essential for clean claims and prompt payment.

Modifier Use

Accurate modifier selection ensures compliant billing and prevents payer denials. For CPT 58100, consider:

  • Modifier 25 – When a significant, separately identifiable E/M service is performed on the same day.
  • Modifier 59 (or XU) – To indicate a distinct procedural service, if another unrelated procedure is done concurrently.
  • Modifier 26 / TC – For professional or technical component billing in facility settings.
  • Modifier 52 – If a limited or incomplete sampling is performed due to anatomical constraints.

Each modifier must be backed by detailed documentation that explains the reason for separate reporting.

Documentation Requirements

Comprehensive documentation supports proper coding, compliance, and reimbursement. For CPT 58100, the operative or procedure note should include:

  • Clinical indication: Specify abnormal bleeding, infertility, or postmenopausal evaluation.
  • Procedure description: Device used (Pipelle, Novak curette), sampling technique, and number of passes.
  • Findings: Uterine size, tissue adequacy, and patient tolerance.
  • Specimen handling: Confirmation that the sample was sent to pathology.
  • Post-procedure care: Instructions for observation and follow-up.

This level of detail ensures compliance with 2025 CMS medical necessity and audit documentation standards.

Example Scenarios

Scenario 1:

A 45-year-old patient presents with abnormal uterine bleeding. The OBGYN performs an endometrial biopsy using a Pipelle sampler without dilation. → Report CPT 58100.

Scenario 2:

A patient with infertility undergoes an endometrial biopsy for luteal phase assessment. → Report CPT 58100.

Scenario 3:

Endometrial biopsy performed with cervical dilation. → Report CPT 58110 instead of 58100.

BillingFreedom – Expert Support for OBGYN Medical Billing

BillingFreedom specializes in OBGYN medical billing, offering precise coding support for diagnostic procedures such as CPT 58100. Our certified coding professionals adhere to AAPC and CMS 2025 standards to ensure documentation accuracy, payer compliance, and complete reimbursement.

Through real-time claim validation, documentation audits, and payer-specific coding reviews, BillingFreedom minimizes denials and strengthens revenue cycle performance for OBGYN practices. We handle the complexities of procedural billing so your clinical team can focus on delivering quality care to patients.

For more details about our exceptional OB/GYN medical billing services, please don't hesitate to contact us via email at info@billingfreedom.com or call us at +1 (855) 415-3472.

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