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Endometrial sampling, commonly referred to as an endometrial biopsy, is a medical procedure that involves the collection of tissue samples from the lining of the uterus (endometrium). This procedure is typically performed to investigate abnormal uterine bleeding or to assess the endometrial lining for conditions such as hyperplasia or cancer. During the procedure, a speculum is inserted into the vagina to allow for visualization and access to the cervix. The cervix is then cleansed with an antiseptic solution to minimize the risk of infection. A tenaculum, which is a surgical instrument used to grasp tissue, is applied to the anterior cervical lip to stabilize the cervix. Following this, the uterus is sounded to determine its depth and orientation. An endometrial curette, a specialized instrument designed for scraping tissue, is then passed through the cervix to collect biopsies from multiple sites within the uterus. In some cases, biopsies may also be taken from the endocervical canal, which is the passageway leading from the cervix to the uterus. After the tissue samples are collected, they are sent to a pathology lab for analysis. The procedure concludes with the removal of the tenaculum and the application of pressure to control any bleeding from the cervix, followed by the removal of the speculum. It is important to note that when this procedure is performed in conjunction with a colposcopy, it is reported using CPT® Code 58110, which is an add-on code. If the endometrial biopsy is performed as a standalone procedure, CPT® Code 58100 should be used instead.
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Endometrial sampling (biopsy) is indicated for several clinical scenarios, particularly when there are concerns regarding the health of the endometrium. The following conditions may warrant this procedure:
The procedure for endometrial sampling performed in conjunction with colposcopy involves several key steps, each critical for ensuring the accuracy and safety of the biopsy.
After the endometrial sampling procedure, patients may experience some cramping or light bleeding, which is generally considered normal. It is important for healthcare providers to inform patients about these potential post-procedure symptoms. Patients are typically advised to monitor for any excessive bleeding or signs of infection, such as fever or unusual discharge, and to report these to their healthcare provider. Follow-up appointments may be scheduled to discuss the results of the pathology report and any further management that may be necessary based on the findings. Additionally, patients should be counseled on activity restrictions, such as avoiding sexual intercourse or the use of tampons for a specified period, to promote healing and prevent complications.
| Short Descr | BX DONE W/COLPOSCOPY ADD-ON | Medium Descr | ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY | Long Descr | Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 130 - Other diagnostic procedures, female organs |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 57420 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the entire vagina, with cervix if present; | 57421 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix | 57452 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; | 57454 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage | 57455 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix | 57456 | Female Edit MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage | 57460 | Female Edit MPFS Status: Active Code APC J1 ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix | 57461 | Female Edit MPFS Status: Active Code APC J1 ASC P3 CPT Assistant Article Illustration for Code Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AG | Primary physician | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2006-01-01 | Added | First appearance in code book in 2006. |
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