Dilation and Curettage (D&C)
5812058100wRVU: 1.18 — Endometrial sampling (biopsy) without cervical dilation58558wRVU: 4.07 — Hysteroscopy with sampling (biopsy) of endometrium and/or polypectomy
[Abnormal uterine bleeding / postmenopausal bleeding / endometrial polyp / endometrial hyperplasia]
Same
Dilation and curettage (D&C) [with hysteroscopy] [and polypectomy]
[***, MD/DO]
[Nurse/tech name]
General endotracheal [/ MAC / spinal / paracervical block with sedation]
The patient is a [age]-year-old [female] with [abnormal uterine bleeding / postmenopausal bleeding / endometrial thickening on ultrasound / endometrial hyperplasia] requiring evaluation and treatment. Endometrial sampling and curettage were recommended [after failed medical management / for tissue diagnosis]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
[Hysteroscopy: The uterine cavity was entered. The endometrial surface was [normal / with a [polyp / submucosal fibroid] at [location]]. The bilateral ostia were [visualized / not visualized]. The cavity measured [X] cm in sounding depth.] Curettage yielded [scant / moderate / abundant] endometrial tissue.
The patient was positioned in the dorsal lithotomy position. The external genitalia and vagina were prepped and draped. A [weighted speculum] was placed. The anterior cervical lip was grasped with a [single-tooth tenaculum] at [12 o'clock]. A sound was passed to determine uterine depth and position: [X] cm.
The cervix was serially dilated with [Hegar / Pratt / Denniston] dilators to [X] mm. [Hysteroscopy: A [5-mm] hysteroscope was introduced with [saline (bipolar or mechanical energy) / glycine (monopolar)] distension media and the cavity was inspected systematically.]
[Polypectomy: An endometrial polyp at [location] was removed with [hysteroscopic scissors / loop resectoscope / polyp forceps / mechanical tissue removal system (TruClear / MyoSure)]; the base was cauterized with a [ball electrode].]
A [sharp curette] was passed systematically over the anterior, posterior, and lateral walls until a uniform gritty texture was reached, indicating the basalis. Curettings were collected in a specimen trap. Adequate tissue was obtained. The tenaculum was removed and cervical hemostasis was confirmed.
None [/ uterine perforation, managed with (observation / laparoscopy)]
Endometrial curettings, sent to pathology [and culture if indicated]
[Polyp, sent to pathology separately]
Minimal
None
The patient was taken to the PACU in stable condition and discharged the same day. Pathology results were to be communicated to the patient at follow-up.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: D&C [with hysteroscopy] [and polypectomy]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/MAC
INDICATIONS: .PTAGE-year-old .PTSEX with ***. Endometrial sampling and curettage recommended. Consent obtained.
FINDINGS: [Hysteroscopy: cavity ***; polyp at ***; ostia ***.] Curettage: *** endometrial tissue.
PROCEDURE:
Lithotomy. Prepped and draped. Weighted speculum. Single-tooth tenaculum on the anterior lip. Sound: *** cm. Serial Hegar/Pratt dilation to *** mm. [Hysteroscopy: 5 mm scope, saline distension; findings above.] [Polypectomy: polyp at ***, removed with ***, base cauterized.] Sharp curettage of all walls until a gritty texture was reached. Adequate tissue obtained and collected in a trap. Tenaculum removed, cervix hemostatic.
EBL: Minimal
SPECIMENS: Endometrial curettings [+ polyp] to pathology
COMPLICATIONS: None
DISPOSITION: Same-day discharge. Results at follow-up.
Signed: .ME, .MYDEGREE
.TODAYCharting Tips
- Document uterine sounding depth and position before dilation. The sound establishes the cavity axis and depth and lowers the chance of a false passage; an unexpectedly shallow depth may reflect a fibroid, prior surgery, or an anomaly and should be described.
- Uterine perforation is the most common serious immediate complication, and the risk is higher with an atrophic postmenopausal uterus. If the sound or curette passes farther than the measured depth or resistance is lost, chart 'suspected perforation' with the depth and the management taken (observation versus laparoscopy).
- Describe the tissue yield. Scant curettings may reflect an atrophic endometrium or an inadequate sample rather than a normal result, which changes how the pathology is read. Aggressive sharp curettage in a reproductive-age patient risks intrauterine adhesions (Asherman syndrome), so limit curettage to what the indication requires.
- For a pregnancy-related uterine evacuation (miscarriage, retained products of conception, molar, or postpartum), use the suction D&C / uterine aspiration note instead; the technique, medication, and coding differ.
Billing Tips
- Bill 58120 for dilation and curettage, nonobstetric (3.50 wRVU, 10-day global). Use for abnormal uterine bleeding, endometrial polyp, or diagnostic endometrial sampling that requires anesthesia and formal cervical dilation.
- Hysteroscopy with D&C uses different codes: 58558 (hysteroscopy with biopsy, 4.07 wRVU) or 58563 (hysteroscopy with endometrial ablation, 4.36 wRVU). If hysteroscopy is performed, do not also bill 58120; the hysteroscopy code includes the curettage.
- 10-day global period: wound checks and routine follow-up within 10 days are bundled. Pathology review and results communication do not generate a separate procedure fee.
- Office endometrial biopsy (58100, 1.18 wRVU) is a distinct procedure from operative D&C. Do not use 58120 for an office Pipelle biopsy; that is 58100. Reserve 58120 for cases requiring anesthesia and formal dilation.
- For a pregnancy-related uterine evacuation (miscarriage, retained products, molar, or postpartum), 58120 is the wrong code. Those bill under the 598xx family (59812, 59820, 59821, 59870) or 59160 for postpartum. Use the suction D&C / uterine aspiration note.
General coding reference. Verify with your institution’s billing department before submitting claims.