Getting paid fairly for surgical procedures hinges on accurate coding. This is particularly true for gynecological procedures, where similar but distinct procedures are billed using different CPT codes. Did you know that insurance companies deny nearly 17% of in-network claims? A major cause is incorrect billing and errors in claim submission.
This denial rate is deeply concerning for critical gynecological procedures. One significant code for these procedures is CPT code 58100. Many medical billers struggle to bill this code correctly.
We created this guide after observing frequent confusion around CPT code 58100’s usage, documentation requirements, and modifier application. So, let’s start.
CPT Code 58100 – Description
The official definition of CPT code 58100 is “Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure).” In this procedure, a surgeon takes a small sample of the uterine wall (endometrium) and sometimes of the cervix if needed (endocervical biopsy).
The entire procedure takes about 10 to 15 minutes and usually involves the following steps:
- The patient is put into a lithotomy position.
- The surgeon inserts a speculum into the vagina to visualize it and the cervix.
- Both the vagina and cervix are cleaned with an antiseptic solution.
- To take the sample, a small flexible tube is inserted through the vagina to the end of the cervix without dilation.
- The sample is gently scraped from the walls, i.e., endometrium and endocervical walls.
- The samples are then sent to the lab for analysis.
Providers use 58100 most when performing an endometrial biopsy to sample the uterine lining for evaluation of abnormal uterine bleeding and to rule out hyperplasia or carcinoma.
Scenarios Where CPT Code 58100 is Applicable
To better understand how to use CPT code 58100 practically, let’s look at some real-world scenarios:
Abnormal Uterine Bleeding
Sarah, a 35-year-old teacher, had been experiencing heavy bleeding for months. Concerned about her health, she consulted Dr. Lee, a gynecologist. After a thorough examination, the doctor could not find a reason for the symptoms. So, he recommended an endometrial biopsy to diagnose the reason for abnormal uterine bleeding.
The procedure was scheduled and performed. Hence, CPT code 58100 was reported. A week later, Sarah received her results, which indicated a benign condition easily treatable with medication.
Irregular Menstrual Cycles
A woman notices that her menstrual cycles have become irregular and very heavy. She visits a gynecologist. To diagnose the condition, the doctor prescribes an endometrial biopsy with cervical samples. The procedure was scheduled for the next day and performed smoothly.
The samples were sent to the lab for analysis. The doctor billed the entire procedure with CPT code 58100. A few days later, Dr. Patel called with the results: there were no signs of cancer, only a hormonal imbalance.
Applicable Modifiers for CPT Code 58100
Let’s now look at some modifiers that you can append to CPT code 58100 to provide additional information about the procedure:
| Modifier | Description | When to Use |
|---|---|---|
| 52 | Partially reduced or discontinued procedure | The provider abandons the procedure or reduces it due to extenuating circumstances that risk the patient’s well-being. |
| 59 | Distinct procedural service | The provider appends it when distinct services/procedures, generally bundled in NCCI edits, were performed on the same day. |
CPT Code 58100 – Billing & Reimbursement Guidelines
Keep denials at bay by following the billing and reimbursement guidelines for code 58100 discussed below.
Use the Correct POS Code
Endometrial biopsy is generally performed at the physician’s office or in an outpatient setting without anesthesia. Therefore, you must use the correct place of service (POS) code with CPT code 58100 on the claim form. For example:
- POS code 11 for the office
- POS code 19 for off-campus, outpatient hospital
- POS code 22 for on-campus, outpatient hospital
Ensure Accurate ICD-10 Linkage
For successful reimbursement, it is essential to report the appropriate ICD-10 codes in the claim. Doing this is necessary to justify the need for the procedure. Some suitable procedure codes for CPT code 58100 are:
- N95.0 (postmenopausal bleeding)
- N88.2 (cervical stenosis)
- N92.6 (irregular menstruation, unspecified)
- C54.1 (endometrial malignancy risk)
Maintain Documentation
Comprehensive documentation is the key to reimbursement. The documentation needs to justify the procedure and the ICD-10 codes. So, the medical report should be comprehensive and must provide details about every minute of service. The attached reports must include:
- Patient symptoms and prior medication records
- Method of biopsy (curettes)
- Results
- Patient tolerance
Avoid Unbundling
Unbundling is another error many billers make while filing a claim for CPT code 58100. Do not bill CPT 58100 with dilation code 57800; when cervical dilation is needed, use 58120 instead.
Wrapping Up
CPT code 58100 is an essential gynecological code. It refers to endometrial sampling (biopsy) without cervical dilation. The process may involve endocervical sampling (biopsy). For proper billing, you must understand the correct usage scenarios, applicable modifiers, and documentation requirements.
However, if you are facing constant claim denials, seeking the assistance of billing experts may help. Our team of professionals can reduce your denials and boost revenue collection. MediBillMD’s OBGYN billing services are designed for healthcare practices of all sizes.
