2025 CPT code 58120

Dilation and curettage, diagnostic and/or therapeutic (non-obstetrical).

Modifiers applicable. Modifier 22 (Increased Procedural Services) can be used if there's significant additional work, such as difficulty with dilation or conversion to a different approach. Modifiers 51, 52, 53, 54, 55, 56, 58, 59, 73, 74, 76, 77, 78, 79, 99, AG, AQ, AR, CR, ET, GA, GC, GJ, GR, KX, PD, Q5, Q6, QJ, XE, XP, XS, and XU might also apply depending on the specific situation.

Medical necessity for a DC is established by the clinical indication, such as abnormal uterine bleeding, retained products of conception, or suspicion of malignancy. The documentation should clearly support the medical reason for performing the procedure.

IMPORTANT For postpartum hemorrhage, use 59160. For pelvic laparotomy, use 49000. For excision or destruction of endometriomas, open method, see 49203-49205, 58957, 58958. For paracentesis, see 49082, 49083, 49084. For secondary closure of abdominal wall evisceration or disruption, use 49900. For fulguration or excision of lesions, laparoscopic approach, use 58662. For chemotherapy, see 96401-96549. Do not report 58120 in addition to a separate code for a diagnostic hysteroscopy. If a hysteroscope is used during the procedure, even if the DC is performed without it, report the more extensive procedure code 58558. Do not report 58120 for curettage related to pregnancy.

In simple words: This procedure widens the cervix to reach the uterus, allowing the doctor to gently scrape its lining. It helps find problems like abnormal bleeding or treat conditions by removing tissue.

This code represents a procedure where the cervix is dilated to access and scrape the uterine lining. It's used for both diagnostic purposes (like identifying the cause of abnormal bleeding or evaluating infertility) and therapeutic treatments (such as removing abnormal tissues or clearing the uterine lining after a miscarriage). The procedure involves dilating the cervix with instruments or medication, and then using a curette (a sharp or suction instrument) to remove uterine tissue for examination.

Example 1: A woman experiencing heavy and irregular menstrual bleeding undergoes a DC to determine the cause and remove any abnormal tissue., Following a miscarriage, a DC is performed to remove the remaining pregnancy tissue from the uterus., A postmenopausal woman with abnormal uterine bleeding has a DC to obtain a tissue sample for evaluation of possible cancer.

Documentation should include the reason for the DC (diagnostic or therapeutic), pre- and post-procedure diagnoses, description of the procedure performed, findings (including any tissue removed), estimated blood loss, and any complications encountered.

  • Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
  • Specialties:Obstetrics and Gynecology
  • Place of Service:Ambulatory Surgical Center, Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital
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