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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.

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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.

Service type: Office or clinic-based diagnostic gynecologic procedure
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

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CPT 58100: Endometrial Biopsy Without Cervical Dilation

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Get alerted when payer policies referencing 58100 are released or updated.

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Billing Code Overview

Service type: Office or clinic-based diagnostic gynecologic procedure
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.

| 53 | Discontinued procedure | When the procedure is terminated due to patient intolerance or complication before tissue obtained.

| 59 | Distinct procedural service | When another distinct procedure (e.g., endocervical biopsy coded separately) is performed and must be indicated as distinct from the primary biopsy.

| 62 | Two surgeons | When another surgeon is required to assist as co-surgeon during an unusual complication (rare for this procedure).

| 76 | Repeat procedure by same physician | When the same physician repeats the endometrial biopsy during the post-procedure period for inadequate sample.

| 77 | Repeat procedure by another physician | When a different physician repeats the biopsy because initial specimen was nondiagnostic.

| 24 | Unrelated E/M service by the same physician during post-operative period | When an unrelated E/M visit occurs during the global period after a related procedure (rare applicability).

| 26 | Professional component | When billing separate professional component only (rare for this encounter; typically global service billed).

| TC | Technical component | When reporting only the technical component (e.g., facility or lab handling) separate from professional service.

| 22 | Unusual procedural services (increased procedural services) | When the procedure required substantially greater work than typical (documented justification required).

| 50 | Bilateral procedure | Generally not applicable to endometrial biopsy; included only when payer-specific reporting requires it for bilateral cervical procedures.

| 76 | Repeat procedure by same physician | (listed for emphasis) see above.

Taxonomy Code	Specialty	Notes
207Q00000X	Obstetrics & Gynecology	Most common specialty performing endometrial biopsy.

| 261QM0800X | Family Medicine | Family physicians with women’s health training may perform office endometrial biopsy.

| 208D00000X | Gynecologic Oncology | Performs biopsies when concern for malignancy or complex pathology.

| 363LP0800X | Physician Assistant | PAs in gynecology or family medicine may perform under supervision per state law.

| 367A00000X | Nurse Practitioner | NPs providing primary or women's health may perform office biopsies under scope of practice.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N92.0`	Excessive and frequent menstruation with regular cycle	Common indication for endometrial biopsy to evaluate causes of heavy bleeding.

| N93.9 | Abnormal uterine and vaginal bleeding, unspecified | Frequent clinical presentation prompting endometrial sampling.

| N95.0 | Postmenopausal bleeding | Key indication for endometrial biopsy to exclude endometrial carcinoma.

| N84.0 | Polyp of corpus uteri | Endometrial biopsy may be used to sample for polyps or to guide further operative management.

| D07.1 | Carcinoma in situ of endometrium | Biopsy used to obtain tissue for diagnosis or surveillance.

| C54.9 | Malignant neoplasm of corpus uteri, unspecified | Biopsy is diagnostic step when malignancy suspected.

| O26.8 | Other specified pregnancy-related conditions (used cautiously) | In nonpregnant reproductive-age patients, pregnancy-related bleeding is ruled out before biopsy; biopsy is contraindicated in known pregnancy.

| R87.619 | Abnormal cytology of cervix, unspecified | Abnormal cervical cytology may prompt concurrent endocervical sampling with the endometrial biopsy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`76830`	Transvaginal ultrasound, limited or follow-up	Often performed before biopsy to evaluate endometrial thickness and guide decision to biopsy.

| 58110 | Endometrial sampling (dilatation and curettage), diagnostic | More invasive endometrial sampling performed when office biopsy is nondiagnostic or when dilation is required; alternative to 58100.

| 57460 | Colposcopy of the cervix including upper/adjacent vagina | May be performed same day if abnormal cervical findings necessitate direct cervical evaluation; not routine with 58100 but related for cervical pathology.

| 88172 | Cytopathology, immediate and direct smears, interpretation on-site | May be used if on-site adequacy assessment of specimen is performed during biopsy.

| 88305 | Level IV surgical pathology, gross and microscopic examination | Common pathology charge for endometrial tissue specimens submitted after biopsy.

CPT 58110: Endometrial Biopsy Performed with Colposcopy

CPT-58120-ENDOMETRIAL-CURETTAGE-DILATION-AND-CURETTAGE

CPT 58120: Dilation and Curettage of Uterine Lining

CPT-58140-ABDOMINAL-MYOMECTOMY-1-TO-4-FIBROIDS-250G-OR-LESS

CPT 58140: Abdominal Myomectomy for 1–4 Uterine Fibroids

CPT-58145-VAGINAL-MYOMECTOMY-UTERINE-FIBROID-EXCISION-1-TO-4-TUMORS

CPT 58145: Vaginal Myomectomy for Excision of 1–4 Uterine Fibroids

CPT-58146-ABDOMINAL-MYOMECTOMY-5-PLUS-FIBROIDS-GT-250G

CPT 58146: Abdominal Myomectomy for 5+ Uterine Fibroids, >250 g

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

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Clinical & Coding Specifications

Clinical Context

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).