Summary & Overview
CPT 58110: Endometrial Biopsy Performed with Colposcopy
CPT code 58110 denotes an add-on procedure for endometrial biopsy performed during the same session as colposcopy. This code clarifies billing when a clinician obtains endometrial tissue while conducting a colposcopic exam, ensuring the procedure is reported distinctly from the primary colposcopy service. Nationally, proper use of this code affects claims accuracy, revenue capture for add-on services, and compliance with payer bundling rules.
This analysis covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of billing context, common modifiers and billing considerations, and how the code is typically used in outpatient gynecologic practice. The publication outlines benchmark expectations and typical payer coverage patterns where available, plus clinical context linking the add-on biopsy to colposcopy sessions.
The report is intended for billing managers, clinical coders, and policy analysts seeking practical guidance on reporting and documentation implications for CPT code 58110. Data not provided in the input (such as payer-specific policy language, ICD-10 pairings, and utilization benchmarks) is noted as unavailable where applicable in the fuller publication.
Billing Code Overview
CPT code 58110 describes an add-on endometrial biopsy performed at the same session as colposcopy. The procedure involves obtaining endometrial tissue during a clinical visit that includes colposcopic evaluation.
Service type: Endometrial biopsy performed in conjunction with colposcopy
Typical site of service: Outpatient clinic or ambulatory procedure setting where colposcopy is performed
Clinical & Coding Specifications
Clinical Context
A 36-year-old woman presents to a gynecology clinic with abnormal uterine bleeding and an abnormal cervical cytology result. The clinician performs a diagnostic colposcopy to evaluate the cervix and, during the same visit, obtains an endometrial biopsy to sample the uterine lining for pathology. The workflow includes patient consent, positioning in the speculum exam chair, application of acetic acid and Lugol's iodine to the cervix for colposcopic assessment, directed cervical biopsies if indicated, and then insertion of an endometrial sampling device (such as a Pipelle) to aspirate endometrial tissue. Specimens are placed in labeled containers and sent to histopathology. Procedure documentation includes indication, findings at colposcopy, details of the endometrial sample, anesthesia or analgesia used, any complications, and the use of modifier(s) as appropriate. Billing uses 58110 as the add-on code when endometrial biopsy is performed at the same session as colposcopy, reported in conjunction with the primary colposcopy procedure code.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Default / No modifier required by payer | Rarely used; included in input list but not typically appended to claims by providers |