Contact us
855-415-3472
Schedule a Demo
x

Let's Get in Touch

Please fill up the form, one of our AAPC certified medical biller and coder will reach out to you.

Product of Interest

CPT Code 58120 Endometrial sampling, D&C and Uterus Tumor Excision Procedures

best medical billing company

Seamless Global Period Tracking and Compliance

Accurate OB Contract Management and Patient Collections

Accurate procedural coding remains essential for OBGYN practices to maintain compliance and ensure timely reimbursement. CPT 58120 is assigned when a physician performs a dilation and curettage (D&C) of the uterus for diagnostic or therapeutic reasons, excluding obstetric cases.

This procedure involves dilating the cervix and removing endometrial tissue from the uterine cavity using a curette or suction device. It is often used to address abnormal uterine bleeding, incomplete miscarriage, or suspected intrauterine pathology. This 2025 guide outlines proper reporting, documentation standards, and coding rules in accordance with AAPC and CMS updates.

CPT 58120 – Code Definition and Overview

Official Code Description: “Dilation and curettage, diagnostic and/or therapeutic (nonobstetric).”

This code represents a non-pregnancy-related uterine curettage performed for diagnostic sampling or therapeutic removal of endometrial contents. The procedure can be done under general or local anesthesia, either in an outpatient surgical center or hospital setting.

Unlike obstetric D&Cs (which use codes 59812–59820), CPT 58120 applies strictly to non-pregnant patients. It may also be reported after a failed office-based biopsy or when endometrial tissue cannot be adequately sampled in the clinic.

When to Report CPT 58120

CPT 58120 should be billed when the OBGYN performs dilation and curettage for medically indicated, non-obstetric conditions, such as:

  • Abnormal uterine bleeding (AUB) or menometrorrhagia
  • Endometrial hyperplasia or suspected malignancy
  • An incomplete abortion occurs when obstetric codes do not apply
  • Postmenopausal bleeding with an inconclusive biopsy
  • Retained intrauterine tissue following non-pregnancy-related pathology

Do not report 58120 if the procedure is performed in conjunction with pregnancy-related care (use obstetric D&C codes) or if the only service is an endometrial biopsy (CPT 58100).

Coding and Billing Guidelines

Under 2025 AAPC and CMS rules, the following guidelines apply:

  • Report 58120 once per session, even if multiple curettage passes are performed.
  • Do not bill 58100 (endometrial biopsy) separately if both are performed on the same day - D&C includes tissue sampling.
  • The global period is 10 days; postoperative visits within this timeframe are bundled.
  • When performed with hysteroscopy (CPT 58558), check for NCCI edits - typically, hysteroscopy supersedes 58120.
  • Always link appropriate ICD-10 codes (e.g., N93.9, N85.00, N95.0) that justify medical necessity.

Reimbursement Insights

CPT 58120 is typically reimbursed under a 10-day global surgical package.

  • Typical site of service: hospital outpatient department or ambulatory surgical center (ASC)
  • Approximate Medicare reimbursement: $175–$220 (region-specific)
  • Multiple surgery reductions apply if performed with other intrauterine procedures

Prior authorization may be required by commercial payers, especially if D&C is performed for diagnostic rather than therapeutic reasons. Documentation should always include the clinical indication and surgical outcome.

Modifier Application

Use modifiers carefully to ensure proper claim adjudication:

  • Modifier 25 – If a significant, separate E/M service is performed on the same day.
  • Modifier 51 – When D&C is performed with another surgical procedure in the same session.
  • Modifier 59 (or XU) – If the D&C is distinct from another uterine procedure (such as hysteroscopy).
  • Modifier 52 – If the planned D&C was only partially completed due to patient or anatomic limitations.

Avoid overuse of modifiers, as improper application can trigger payer audits or claim denials.

Documentation Standards

For CPT 58120, operative documentation must clearly demonstrate both clinical necessity and procedure completion. Essential details include:

  • Preoperative diagnosis and indication for D&C
  • Findings on uterine inspection
  • Method of cervical dilation and curettage
  • Type of anesthesia and instruments used
  • Specimen confirmation sent to pathology
  • Any complications or immediate postoperative notes

Thorough, well-structured notes ensure coding accuracy and compliance during payer audits.

Example Scenarios

Scenario 1:

A 45-year-old patient with abnormal uterine bleeding undergoes diagnostic D&C after failed office biopsy. → Report CPT 58120.

Scenario 2:

D&C is performed following a miscarriage. → Use obstetric code 59812, not 58120.

Scenario 3:

A D&C is performed with hysteroscopy for intrauterine mass removal. → Report 58558 (do not code 58120 separately).

BillingFreedom – Advancing OBGYN Medical Billing Efficiency

At BillingFreedom, we deliver specialized OBGYN medical billing solutions that ensure accurate procedural coding, error-free claim submission, and compliance with 2025 AAPC and CMS updates. Our team understands the clinical and regulatory complexities of gynecologic procedures like CPT 58120 and aligns documentation with payer expectations.

Through proactive denial prevention, modifier accuracy, and claims analytics, BillingFreedom helps OBGYN practices improve cash flow, maintain audit readiness, and achieve consistent revenue performance - letting providers focus on patient outcomes instead of administrative hurdles.

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.

Your financial tranquility is our priority!

 

Related ICD-10-CM Codes

ICD-10-CM Codes

Related CPT Codes

CPT Codes