Dilation and Curettage (D&C)

CPT 58120
Approach Endoscopic
Add-on / Variant CPTs
  • 58100 — Endometrial sampling (biopsy) without cervical dilation
  • 58558 — Hysteroscopy with sampling (biopsy) of endometrium and/or polypectomy
Preoperative Diagnosis:

[Abnormal uterine bleeding / incomplete abortion / postmenopausal bleeding / endometrial polyp / retained products of conception]

Postoperative Diagnosis:

Same

Procedure Performed:

Dilation and curettage (D&C) [with hysteroscopy] [and polypectomy]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

General endotracheal [/ MAC / spinal / paracervical block with sedation]

Indications:

The patient is a [age]-year-old [female] with [abnormal uterine bleeding / postmenopausal bleeding / endometrial thickening on ultrasound / incomplete abortion] requiring evaluation and treatment. Endometrial sampling was recommended. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

[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.]

Description of Procedure:

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] dilators to [X] mm. [Hysteroscopy: A [5-mm] hysteroscope was introduced into the uterine cavity with [saline] 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]. The base was cauterized with [ball electrode].]

[Suction curettage: A [X-mm] suction cannula was placed and connected to [20 mmHg] suction. 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.

Complications:

None [/ uterine perforation, managed with (observation / laparoscopy)]

Specimens:

Endometrial curettings, sent to pathology [and culture if indicated]
[Polyp, sent to pathology separately]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

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, 20 mmHg, 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
.TODAY
Variants

Manual Vacuum Aspiration (MVA) for Incomplete Abortion

For early pregnancy loss / incomplete abortion at [X weeks], manual vacuum aspiration was performed. A [6–10]-mm MVA cannula was 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 serious complication of D&C. 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). Failure to document a known perforation is indefensible.
  • 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, 5.98 wRVU) or 58563 (hysteroscopy with endometrial ablation). 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, 1.36 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.