Summary & Overview
CPT 58100: Endometrial Biopsy Without Cervical Dilation
CPT code 58100 denotes an endometrial biopsy without cervical dilation, a common outpatient gynecologic diagnostic procedure used to obtain uterine lining tissue for evaluation. Nationally, this code is a routine component of diagnostic pathways for abnormal uterine bleeding, postmenopausal bleeding, and other indications where endometrial sampling guides clinical decision-making. Its proper use affects claims accuracy, payment consistency, and quality measurement in women’s health services.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of coding context and clinical setting, common payer coverage patterns, and the types of benchmarks and policy considerations that affect endometrial sampling services. The publication outlines how payers approach coverage and prior authorization trends, typical payment considerations for outpatient gynecologic procedures, and common modifier usage patterns that may accompany this service.
This analysis provides clinicians, billing staff, and policy stakeholders with practical context: the clinical purpose of the procedure, where it is typically performed, and the payer landscape that influences reimbursement and administrative requirements. Data not available in the input is clearly identified where applicable.
Billing Code Overview
CPT code 58100 describes an endometrial biopsy performed without cervical dilation, in which the provider obtains a tissue sample from the uterine lining. The procedure may also include an endocervical biopsy when clinically indicated.
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Service type: Office or clinic-based diagnostic gynecologic procedure
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Typical site of service: Ambulatory care setting such as an outpatient clinic or physician office; may also be performed in an ambulatory surgical center when indicated
Clinical & Coding Specifications
Clinical Context
A typical patient is a 48-year-old woman presenting to a gynecology clinic with abnormal uterine bleeding, postmenopausal bleeding, or persistent intermenstrual spotting. After history, pelvic exam, and noninvasive testing (pregnancy test, pelvic ultrasound as indicated), the clinician recommends an outpatient endometrial biopsy to obtain tissue for histologic evaluation. The procedure is performed in an exam room or minor procedure suite: the patient is placed in lithotomy position, a speculum is inserted, the cervix is cleansed, and a single-operator endometrial biopsy instrument is passed through the cervical canal without mechanical dilation to sample the endometrial lining. Local anesthesia or paracervical block may be used for comfort. An endocervical curettage or biopsy may be obtained in the same encounter if indicated. Specimens are submitted to pathology for evaluation of hyperplasia, malignancy, or other endometrial pathology. The encounter typically includes pre-procedure counseling, consent, specimen collection, and brief post-procedure observation before discharge to home.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable E/M service by the same physician on the same day as a procedure | When a distinct evaluation and management visit is provided on the same day as the biopsy (e.g., new problem focused visit leading to biopsy). |
| 52 | Reduced services | When the biopsy is attempted but not completed to the full extent (e.g., inadequate sampling due to cervical stenosis) and full service not performed.