CPT® Code 58110

Add-On Code

Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure)

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.