Summary & Overview

HCPCS G9824: Endometrial Sampling or Hysteroscopy with Biopsy, Results Not Documented

HCPCS Level II code G9824 identifies cases where an endometrial sampling or hysteroscopy with biopsy has been performed but results are not documented within the 12 months prior to an endometrial ablation. This measure is relevant for clinical documentation, pre-procedure quality assurance, and payer coverage determinations across the United States. Clear documentation of prior diagnostic results can affect pre-procedure risk assessment and administrative adjudication.

Key payers considered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise review of the code's clinical meaning, typical settings where the service occurs, and the documentation gap that G9824 represents. The publication highlights benchmarks and policy considerations tied to documentation and pre-ablation evaluation, summarizes common modifier usage (input provided), and outlines areas where documentation practices drive coding and claims outcomes.

This summary is intended for clinicians, coders, and payer policy staff seeking a national-level briefing on the code's purpose, clinical context, and implications for pre-procedure documentation and claims processing. Data not available in the input for payer-specific coverage rules or utilization metrics.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9824HCPCS Level IIendometrial samplinghysteroscopy with biopsyendometrial ablationclinical documentationpre-procedure assessmentambulatory surgeryclaims coding

Billing Code Overview

HCPCS Level II code G9824 describes an endometrial sampling or hysteroscopy with biopsy where results are not documented during the 12 months prior to the index date (exclusive of the index date) of the endometrial ablation. The code indicates that no record of a prior diagnostic endometrial sampling or hysteroscopic biopsy with documented results exists in the 12 months before the endometrial ablation procedure.

Service type: Diagnostic endometrial sampling or hysteroscopy with biopsy related to pre-procedure assessment for endometrial ablation
Typical site of service: Ambulatory surgical center or hospital outpatient department where endometrial ablation and associated diagnostic procedures are performed

Data not available in the input for associated taxonomies, ICD-10 diagnoses, or related codes.

Clinical & Coding Specifications

Clinical Context

A typical patient is a premenopausal or perimenopausal woman presenting to gynecology for evaluation of abnormal uterine bleeding, heavy menstrual bleeding, or persistent vaginal spotting despite medical management. The patient has a scheduled endometrial ablation procedure to reduce menstrual blood loss. During preoperative chart review and the visit within the prior 12 months (exclusive of the ablation index date), there is no documented endometrial sampling or hysteroscopy with biopsy and results. The clinical workflow includes preoperative assessment by the gynecologist, review of prior pathology and procedure notes, informed consent, performance of the endometrial ablation in an ambulatory surgery center or hospital outpatient department, and perioperative documentation. When endometrial sampling or hysteroscopic-directed biopsy was not performed or results are not available within the required 12-month window, the billing code G9824 is used to indicate absence of documented endometrial sampling/hysteroscopy with biopsy and results during the specified timeframe.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work or complexity substantially exceeds typical for the ablation and well-documented rationale exists.
`23`	Unusual anesthesia	Use when general anesthesia is medically necessary for a procedure typically done under local/regional sedation.
`52`	Reduced services	Use when a partially reduced service was performed (e.g., ablation started but not completed for clinical reasons).
`53`	Discontinued procedure	Use when the ablation was begun but terminated due to extenuating circumstances or patient safety.
`54`	Surgical care only	Use when only the surgical portion is billed and another practitioner bills pre/postoperative care.
`55`	Postoperative management only	Use when only postoperative care is billed by a practitioner separate from the surgeon.
`56`	Preoperative management only	Use when only preoperative evaluation and management are billed by a practitioner separate from the surgeon.
`62`	Two surgeons	Use when two surgeons of different specialties perform distinct portions of the procedure.
`AS`	Ambulatory surgery center facility	Use to indicate the procedure was performed in an ambulatory surgery center.
`QX`	CRNA service furnished with medical direction by physician	Use for anesthesia services when a CRNA provides services under medical direction.

Taxonomy Code	Specialty	Notes
`163W00000X`	Obstetrics & Gynecology	Gynecologists commonly perform endometrial ablation and related diagnostic sampling.
`2084P0800X`	Gynecologic Oncology	Gynecologic oncologists perform diagnostic endometrial sampling when neoplasia is a concern.
`207V00000X`	Reproductive Endocrinology/Infertility	Specialists who may evaluate abnormal bleeding and manage hormonal therapy prior to procedural intervention.
`208D00000X`	Family Medicine	Family physicians with procedural interest may refer or perform initial evaluation and some procedures.
`3336C0002X`	Ambulatory Surgery Facility	Facility taxonomy representing sites where ablation procedures are commonly performed.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N92.0`	Excessive and frequent menstruation with regular cycle	Common indication for endometrial ablation to control heavy menstrual bleeding.
`N92.1`	Excessive irregular menstruation	Indicates abnormal bleeding patterns leading to consideration of ablation.
`N93.9`	Abnormal uterine and vaginal bleeding, unspecified	General diagnosis prompting evaluation and possible ablation.
`N85.0`	Endometrial hyperplasia without atypia	A condition that requires tissue sampling prior to definitive ablation to exclude neoplasia.
`N84.0`	Polyp of corpus uteri	Endometrial polyps frequently evaluated via hysteroscopy and may be sampled or removed prior to ablation.
`N91.2`	Oligomenorrhea	Less commonly an indication, but relates to menstrual cycle disorders addressed in gynecologic evaluation.
`C54.1`	Malignant neoplasm of endometrium	Absolute contraindication to endometrial ablation; suspicion mandates sampling and pathology prior to any ablative therapy.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`58100`	Endometrial sampling (biopsy) without cervical dilation	Performed preoperatively to obtain tissue for pathology when indicated prior to ablation.
`58558`	Hysteroscopy, diagnostic (separate procedure)	Diagnostic hysteroscopy used to evaluate the uterine cavity before ablation; may include directed biopsy.
`58562`	Hysteroscopy, operative, with endometrial ablation (any method)	The primary operative CPT for performing endometrial ablation; represents the definitive procedural code.
`01936`	Anesthesia for intrauterine procedures including hysteroscopy	Anesthesia services that may be reported when general or regional anesthesia is provided for ablation or hysteroscopy.
`99024`	Postoperative follow-up visit, typically included in global period; reported rarely for unrelated services	Related to postoperative care; ordinarily included in the global surgical package but may be relevant if separate E/M is required.