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 / incomplete abortion / missed abortion / retained products of conception / molar pregnancy / endometrial hyperplasia]
Same
Dilation and curettage (D&C) [with hysteroscopy] [and polypectomy]
[Attending name], 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 / incomplete abortion / missed abortion / molar pregnancy / endometrial hyperplasia] requiring evaluation and treatment. Endometrial sampling was recommended. The risks, benefits, and alternatives were discussed and informed consent was obtained.
[Hysteroscopy: The uterine cavity was entered. The endometrial surface was [normal / with [polyp / submucosal fibroid] at [X] location. The bilateral ostia were [visualized / not visualized]. The cavity measured [X] cm sounding depth.] Curettage yielded [scant / moderate / abundant] endometrial tissue. [Retained products of conception were confirmed and removed.]
The patient was positioned in the dorsal lithotomy position. The external genitalia and vagina were prepped and draped. A [weighted speculum] was placed. The cervix was grasped with a [single-tooth tenaculum] at [12 o'clock]. A sound was passed to determine uterine depth: [X] cm.
The cervix was serially dilated with [Hegar / Pratt / Denniston] dilators to [X] mm. [Hysteroscopy: A [5-mm] hysteroscope was introduced into the uterine cavity with [saline (bipolar or mechanical energy) / glycine (monopolar)] distension media. The cavity was inspected systematically.]
[Polypectomy: An endometrial polyp was identified at [X] position. It was removed with [hysteroscopic scissors / loop resectoscope / polyp forceps / mechanical tissue removal system (TruClear / MyoSure)]. The base was cauterized with [ball electrode].]
[Suction curettage: A [X-mm] suction cannula was placed and connected to suction (400–600 mmHg negative pressure, EVA). The uterine cavity was evacuated with systematic circumferential passes.]
[Sharp curettage: A [sharp curette] was used to systematically curette the uterine cavity in a circumferential fashion. Curettings were collected in a specimen trap.]
Adequate tissue was obtained. The tenaculum was removed and hemostasis at the cervix 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. The patient was discharged 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 recommended. Consent obtained.
FINDINGS: [Hysteroscopy: cavity ***; polyp at ***; ostia ***.] Curettage: *** tissue. [RPOC confirmed/removed.]
PROCEDURE:
Lithotomy. Prepped. Weighted speculum. Single-tooth tenaculum at 12 o'clock. Sound: *** cm. Hegar/Pratt dilation to *** mm. [Hysteroscopy: 5 mm scope, saline distension; findings above.] [Polypectomy: polyp at ***, removed with ***, base cauterized.] [Suction: *** mm cannula, 400–600 mmHg negative pressure, circumferential passes.] [Sharp curette: circumferential.] Adequate tissue obtained. Tenaculum removed, hemostatic.
EBL: Minimal
SPECIMENS: Endometrial curettings [+ polyp] to pathology
COMPLICATIONS: None
DISPOSITION: Same-day discharge. Results at follow-up.
Signed: .ME, .MYDEGREE
.TODAYVariants
Manual Vacuum Aspiration (MVA) for Incomplete Abortion
For early pregnancy loss / incomplete abortion at [X weeks], manual vacuum aspiration was performed. A [4–12]-mm MVA (Karman) cannula was selected based on gestational age (cannula diameter in mm approximates gestational age in weeks) and introduced through the dilated cervix. Suction was applied with the MVA syringe and the cavity was evacuated with circumferential passes until a gritty sensation and pink frothy tissue were obtained, indicating complete evacuation. RPOC were confirmed on gross inspection and sent to pathology. MVA is appropriate for first-trimester pregnancy loss and is associated with less tissue damage than sharp curettage.
Charting Tips
- Document uterine sounding depth before dilation. The sound depth establishes the baseline uterine cavity dimension and confirms you are in the correct plane. An unexpected shallow depth may indicate a fibroid, prior surgery, or anatomic anomaly. Document the finding.
- Document perforation if it occurs. Uterine perforation is the most common immediate serious complication in nonpregnant D&C (rate ~0.3% premenopausal, ~2.6% postmenopausal); hemorrhage is equally significant in pregnant patients. If the sound or curette passes to an unexpected depth or resistance is lost, document 'suspected perforation at [X] cm' and the management (observation, laparoscopy). Intrauterine adhesions (Asherman syndrome) are the most significant long-term complication of aggressive sharp curettage — this is why suction aspiration is preferred over sharp curettage for endometrial evacuation in reproductive-age women.
- Document tissue yield. 'Scant' tissue may indicate an atrophic endometrium, insufficient sampling, or technical failure. 'Abundant' tissue with grape-like vesicles should raise concern for molar pregnancy. Document the gross appearance of the curettings.
Billing Tips
- Bill 58120 for dilation and curettage, nonobstetric (3.50 wRVU, 10-day global). Use for D&C for abnormal uterine bleeding, endometrial polyp, or diagnostic endometrial sampling requiring dilation.
- Bill 59160 for curettage postpartum (2.69 wRVU, 10-day global). Use for retained products of conception after delivery. This is not the same code as nonobstetric D&C.
- 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 use 58120. Use the hysteroscopy code instead.
- 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 office Pipelle biopsy; that is 58100. Reserve 58120 for cases requiring anesthesia and formal dilation.
General coding reference. Verify with your institution’s billing department before submitting claims.