CPT Code 58140 Endometrial sampling, D&C and Uterus Tumor Excision Procedures

Accurate CPT reporting is essential for OBGYN providers performing diagnostic or therapeutic dilation and curettage (D&C) to ensure compliance, support reimbursement, and maintain audit readiness. CPT 58140 describes a non-obstetrical D&C, performed for a variety of gynecologic indications such as abnormal uterine bleeding, incomplete miscarriage, or tissue sampling for pathology.

This procedure remains one of the most frequently reported gynecologic interventions, and understanding payer requirements under CMS and AAPC 2025 guidelines is critical for compliant and efficient billing.

Procedure Overview Of CPT 58140

Official Definition: “Dilation and curettage, diagnostic and/or therapeutic (non-obstetrical).”

This code represents the dilation of the cervix followed by curettage (scraping) of the endometrial lining. The goal may be diagnostic, such as investigating abnormal uterine bleeding or postmenopausal spotting, or therapeutic, such as removing retained tissue after a miscarriage.

If the D&C is performed following delivery or abortion, it should not be reported with 58140; instead, use 59812–59820 as appropriate.

Similarly, if performed as part of a more extensive surgical procedure (e.g., hysteroscopy), it is bundled into that primary code.

When to Report CPT 58140

CPT 58140 is reported when a non-obstetrical D&C is performed for medical necessity and not as part of another major surgical procedure.

Common Clinical Indications:

• Abnormal uterine bleeding not responding to medical therapy
• Postmenopausal bleeding
• Endometrial hyperplasia or suspected malignancy
• Retained products of conception (non-obstetric)
• Evaluation of intrauterine pathology following an inconclusive ultrasound or biopsy

Do not report 58140 when:

• Performed with hysteroscopy (report 58558 instead)
• Performed postpartum or postabortion (use 59812–59820)
• Done solely for specimen collection with Pap test (use cytopathology codes)

CPT 58140 - Documentation and Coding Considerations

Per CMS 2025 and AAPC guidance, documentation must clearly establish medical necessity and the diagnostic or therapeutic intent.

To support 58140, operative notes should include:

• Clinical indication (e.g., abnormal bleeding, incomplete miscarriage)
• Procedure description (dilation size, type of curette, amount of tissue obtained)
• Findings (appearance of endometrium, retained tissue, or polyps)
• Pathology submission confirmation
• Any complications or follow-up plan

CPT 58140 has a 10-day global period. All postoperative care related to the D&C within this timeframe is bundled into the payment. If a separate E/M service is provided on the same day for unrelated reasons, append modifier 25 with documentation supporting medical necessity.

Reimbursement and Payment Insights

Under the 2025 Medicare Physician Fee Schedule, CPT 58140 is reimbursed at an average of $160–$190 (region-dependent). The procedure is typically performed in an outpatient hospital or ambulatory surgical center setting.

Commercial payers often follow Medicare’s coverage policy but may require prior authorization for therapeutic D&Cs performed repeatedly or within short intervals.

Key points:

• Global period: 10 days
• Multiple procedure reduction: applies if performed with other surgical services
• Site of service: hospital, outpatient, or ASC

Appropriate Modifier Use For CPT Code 58140

Modifiers ensure clarity in reimbursement and prevent claim denials when multiple services occur during the same session.

• Modifier 25: Significant, separately identifiable E/M service on the same date
• Modifier 51: Multiple procedures
• Modifier 59 (or XU): Distinct procedural service, if unrelated to another procedure
• Modifiers 26/TC: Used for professional vs. technical components when billing hospital-based services

Avoid unsubstantiated modifier use, as payers frequently audit 58140 claims for over-reporting or bundling errors.

Practical Coding Scenarios

Scenario 1:

A 48-year-old patient presents with heavy, irregular uterine bleeding. After an inconclusive endometrial biopsy, the provider performs a diagnostic D&C to obtain a more representative sample. → Report 58140.

Scenario 2:

A D&C is performed during hysteroscopy to remove endometrial polyps. → Do not report 58140 separately; it’s bundled under 58558.

Scenario 3:

A patient with retained endometrial tissue after miscarriage undergoes a D&C, not related to pregnancy care. → CPT 58140 is appropriate.

Scenario 4:

During a follow-up visit, unrelated urinary symptoms are addressed on the same day as the D&C. → Report 58140 + E/M code with modifier 25.

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