CPT® Code 58120

The procedure described by CPT® Code 58120 refers to a dilation and curettage (D&C) that is performed for diagnostic and/or therapeutic purposes in a nonobstetrical context. This procedure involves several critical steps aimed at accessing the uterine cavity for examination and treatment. Initially, a speculum is inserted into the vagina to allow visualization and access to the cervix. The cervix is then cleansed with an antiseptic solution to minimize the risk of infection. A tenaculum, a surgical instrument with a hook-like end, is used to grasp the anterior lip of the cervix, providing stability during the procedure. To assess the depth and angle of the uterus, a sound—a thin, rod-like instrument—is passed through the cervix. This step is crucial for ensuring that the subsequent dilation is performed safely and effectively. The cervix is numbed to reduce discomfort, and dilation is achieved by inserting a series of metal rods, known as dilators, which gradually increase in diameter. Alternatively, a laminaria tent may be utilized, which is a type of absorbent material inserted into the cervix hours before the procedure. As the laminaria absorbs moisture, it expands, gently dilating the cervical canal over time. During the D&C, biopsies may be taken from the endocervical canal to obtain tissue samples for further examination. A curette, a surgical instrument designed for scraping, is then inserted through the cervix to scrape or suction the uterine wall, allowing for the removal of tissue. The collected endocervical and endometrial tissue is subsequently sent for pathology examination to assess for any abnormalities. After the procedure is completed, the tenaculum is removed, and any bleeding from the cervix is managed through the application of pressure, ensuring patient safety and comfort.