Assigning Dilatation and Curettage Codes
Peggy M. Hapner, CCS, RRA
When should code 58120 for dilatation and curettage (D&C) be as-signed? Coders fr equently have this question when they are assigning CPT™ codes for procedures performed on the female genital system. Part of the confusion arises because, in many instances, the American Medical Association (AMA) has included the D&C as an integral component of many other female genital system procedures.
The following case studies may provide some insight on when to assign code 58120 and when not to assign it.
Case 1: Cervical Dysplasia
Procedure: Cold knife conization of the cervix, fractional dilatation and curettage
Under general anesthesia, the patient was prepped with Betadine solution, placed in the dorsolithotomy position and draped appropriately. Exam under anesthesia revealed a small anteflexed uterus but no adnexal masses.
A weighted speculum was inserted in the vagina. A single-toothed tenaculum was used to grasp the anterior lip of the cervix. The squamocolumnar junction was easily visualized.
Using one ampule of Pitressin solution and 60 cc of saline, the entire ectocervix was injected with the hemostasis. The uterus was sounded to 6 cm and determined to be anteflexed.
Using a #11 blade on a curved knife handle, a 360-degree cold knife cone of the entire transformation zone was performed. The specimen was submitted in two pieces.
At this point endocervical curettement yielded an additional amount of minimal tissue. The endocervical os was dilated with the Pratt dilators and endometrial cavity curetted in all 360 degrees, yielding minimal endometrial tissue. The ectocervical base was suctioned and treated with ball cautery at a 55-watt cauterization, as were the cold knife cone specimen margins. This gave complete hemostasis.
A piece of Surgicel was applied, and the single-toothed tenaculum and weighted speculum were removed. Estimated blood loss was minimal. The patient tolerated the procedure well and left the operative room in good condition.
622.1 Dysplasia of cervix
57520 Conization of the cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser
The code description for the conization of the cervix includes the dilatation and curettage performed. The pelvic exam under anesthesia is also included in the conization procedure.
Case 2: Menometrorrhagia
Procedure: Fractional D&C
Under general anesthesia, the patient was placed in the lithotomy position, prepped and draped in the usual manner. A bimanual examination revealed normal-looking external genitalia and vaginal walls. The cervix revealed no abnormalities. The uterus was retroverted, mobile and about normal in size. Adnexal area was clear.
The weighted speculum was inserted in the posterior fornix. The anterior lip of the cervix was held with a single tooth tenaculum. The uterocervical canal measured 3 1/2 inches. The cervix was separately curetted and dilated with a dilator. The uterine cavity curetted sharply. A moderate amount of normal-looking tissues was obtained. No polyp was found. Patient’s condition at the end of surgery was satisfactory.
Pathological Findings: Uterine, endocervical squamous metaplasia; uterine, endometrial secretory endometrium postovulatory day four to five
58120 Dilatation and curettage, diagnostic and/or therapeutic (nonobstetrical)
In this example, the only procedure performed was the dilatation and curettage, therefore, assign CPT code 58120 only.
Case 3: Abnormal Uterine Bleeding
Procedure: Hysteroscopy and D&C
An approximately 8-mm polyp was found in the patient’s cervix. The remainder of the endocervix was remarkable. Uterine cavity was somewhat difficult to visualize but no obvious abnormalities. Minimal tissue on D&C.
The patient was taken to the OR with an IV in place, received general anesthesia and was placed on the operating room table in semidorsolithotomy position with her legs held by the staff. She was then prepped and draped, and a pelvic exam was performed.
Weighted speculum was placed and single tooth tenaculum placed anteriorly on the cervix. Visualization was good. Diagnostic hysteroscope was introduced into the endocervix on direct visualization and into the intrauterine cavity. The above findings were noted with no obvious pathology. The cervical polyp was removed by sharp curette.
The hysteroscope was withdrawn, and cervical dilation to #8 Hagar was performed. Sharp uterine curette was introduced, and the uterine cavity systematically curetted with a minimal amount of tissue. Bleeding was negligible, and the procedure was terminated. The patient tolerated the procedure well.
626.8 Dysfunctional uterine hemorrhage, not otherwise specified
56351 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
In this example, the physician performed both a hysteroscopy and a D&C. The code description for CPT code 56351 includes the D&C procedure and, therefore, code 58120 should not be assigned. *
Peggy Hapner is a senior health care consultant and outpatient coding expert with Medical Learning Inc. (MedLearn), St. Paul, MN.
*CPT is a registered trademark of the American Medical Association.