CPT code for dilation and curettage, or D&C, describes a common outpatient procedure in which the cervix is gently widened and the uterine lining is removed. Accurate coding and documentation help ensure appropriate reimbursement, support medical necessity, and align billing with clinical practice.
Below is a concise reference that clinicians, billers, and patients can use to understand how this service is categorized, documented, and reported in everyday practice.
| CPT Code | Short Description | Body System | Typical Setting |
|---|---|---|---|
| 58120 | Dilation and Curettage, diagnostic | Female Reproductive | Hospital outpatient, ASC, office OR |
| 58140 | Dilation and Curettage, therapeutic | Female Reproductive | Hospital outpatient, ASC, office OR |
| 58299 | Unlisted procedure, female reproductive system | Female Reproductive | |
| 58100 | Hysterectomy, other than specified vaginal or abdominal approach | Female Reproductive | May be reported separately when a D&C is part of a larger procedure |
Diagnostic Dilation and Curettage Coding Details
Purpose and Documentation Requirements
Code 58120 is assigned when the primary goal is to evaluate abnormal uterine bleeding, evaluate endometrial lining, or obtain tissue for pathologic examination. Payers expect clear documentation that medical necessity exists, such as inconclusive imaging, persistent irregular bleeding, or suspicion of hyperplasia.
Key Components and Global Period
Global surgical services rules apply, meaning the preoperative and postoperative care, along with the procedure itself, are typically bundled into 58120. The global period is ninety days for hospital outpatient and ASC settings. Separate reporting of cervical dilation, endometrial sampling, or curettage is not permitted when 58120 is performed.
Modifiers and Payer Policies
Modifiers may be used when necessary; for example, modifier -53 for discontinued procedures or modifier -76 when repeat procedures are performed by the same provider. Payer policies can vary, so confirming medical necessity criteria, preauthorization rules, and documentation expectations helps reduce denials and delayed payments.
Therapeutic Dilation and Curettage Coding Details
Indications and Clinical Context
Code 58140 applies when the procedure is performed to address retained products of conception, manage abnormal bleeding due to structural lesions, or perform procedures such as evacuation of incomplete miscarriage. Documentation should clearly state the therapeutic objective and any intraoperative findings that justify the intervention.
Procedure Components and Reporting Rules
The therapeutic D&C includes cervical dilation and endometrial curettage, so these elements are not reported separately. If additional significant procedures are required, such as removal of adhesions or lysis of intrauterine synechiae, consider whether add-on codes or an unlisted code better reflect the service provided.
Payer Considerations and Medical Necessity
Medical necessity is often linked to abnormal imaging, failed medical management, or clinical symptoms that require tissue diagnosis or evacuation. Accurate procedural notes, including indication, intraoperative findings, and specimen details, support appropriate reimbursement and reduce the risk of audit or denial.
Unlisted Codes and Complex Scenarios
When to Use 58299
Use 58299 when the intrauterine procedure does not fit the definition of a standard diagnostic or therapeutic D&C. Examples include extensive intraoperative lysis of adhesions, complex reconstruction, or procedures combined with major operative interventions that cannot be described by a specific code.
Documentation Strategies to Support Unlisted Claims
Detailed operative notes, intraoperative photographs when appropriate, and clear linkage between the clinical problem and the service provided strengthen unlisted code submissions. Including a written report of medical necessity and, if required, obtaining prior payer approval can improve timely payment and minimize appeals.
Comparative Overview of Common Female Reproductive Codes
| CPT Code | Procedure Type | Typical Clinical Use | Billing Considerations |
|---|---|---|---|
| 58120 | Diagnostic D&C | Endometrial sampling for abnormal bleeding | Bundled global period; requires clear medical necessity |
| 58140 | Therapeutic D&C | Management of miscarriage, retained products | Bundled global period; focus on therapeutic intent |
| 58299 | Unlisted Female Reproductive | Complex intrauterine procedures | Detailed documentation and payer clarity required |
| 58100 | Hysterectomy, other approaches | Removal of the uterus | Major surgery; reported separately if performed |
Streamlined Reporting and Practice Considerations
Establishing consistent documentation habits and clear communication with coding staff supports accurate CPT reporting for dilation and curettage. Aligning clinical notes with payer expectations improves clean claim rates and reduces administrative friction.
- Verify payer-specific medical necessity criteria before scheduling a D&C.
- Document intraoperative findings, specimen type, and clinical indication thoroughly.
- Confirm global period rules when multiple services are performed during the same encounter.
- Use modifier 53, 76, or unlisted codes when the service deviates from standard reporting expectations.
- Review coding updates and payer policies annually to maintain compliance and accuracy.
FAQ
Reader questions
How do I choose between CPT 58120 and 58140 for a D&C?
Use 58120 when the purpose is diagnostic evaluation, such as pathologic assessment of abnormal endometrial tissue. Use 58140 when the primary intent is therapeutic, such as evacuation of retained products or management of incomplete miscarriage.
Can cervical dilation be reported separately from a D&C?
No, cervical dilation is an inherent component of both diagnostic and therapeutic D&C codes and should not be reported separately to avoid improper payment and potential audit concerns.
What documentation supports medical necessity for a D&C?
Documentation should include the clinical indication, results of prior testing, intraoperative findings, description of the procedure performed, and details about any specimens obtained to ensure alignment with payer requirements.
Are add-on codes ever used with a D&C procedure?
Add-on codes are typically not used with D&C because the procedure includes standard components. Consider unlisted code 58299 only when the service involves significant additional work that does not have a specific CPT descriptor.