ICD-10 Coding for Dilation and Curettage(58120, 59840)
Complete ICD-10-CM coding and documentation guide for Dilation and Curettage. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dilation and Curettage
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| 58120 | Non-obstetrical Dilation and Curettage | For non-pregnancy-related indications such as abnormal bleeding or endometrial sampling. |
|
| 59840 | 1st-trimester abortion | For pregnancy termination procedures within the first trimester. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dilation and curettage
Essential facts and insights about Dilation and Curettage
Primary ICD-10-CM Codes for dilation and curettage
Decision Criteria
clinical Criteria
- Presence of abnormal uterine bleeding or endometrial pathology
Applicable To
- Abnormal uterine bleeding
- Endometrial sampling
Excludes
- Obstetrical D&C
Clinical Validation Requirements
- Abnormal ultrasound findings
- Pathology report confirming hyperplasia or cancer
Code-Specific Risks
- Incorrectly coding as obstetrical D&C
- Omitting documentation of cervical dilation
Coding Notes
- Ensure documentation specifies non-obstetrical indication.
59840 - 1st-trimester abortion
For pregnancy termination procedures within the first trimester.
Applicable To
- Elective abortion
- Surgical abortion with suction curettage
Excludes
- Non-obstetrical D&C
Clinical Validation Requirements
- Positive pregnancy test
- Ultrasound confirming intrauterine pregnancy ≤14 weeks
Coding Notes
Ensure documentation includes gestational age and method used.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dilation and Curettage to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code 58120.
Impact
Clinical: Inaccurate clinical records, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always document gestational age in the procedure note, Cross-check with ultrasound reports
Impact
Reimbursement: May lead to incorrect billing and reimbursement issues., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Verify documentation of suction curettage vs. forceps evacuation.
Impact
Incorrect use of modifiers during global periods can lead to audits.
Mitigation Strategy
Ensure documentation clearly supports the use of modifiers like -24.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dilation and Curettage, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dilation and Curettage
Use these documentation templates to ensure complete and accurate documentation for Dilation and Curettage. These templates include all required elements for proper coding and billing.
Non-obstetrical D&C for postmenopausal bleeding
Specialty: GynecologyRequired Elements
- Indication for procedure
- Technique used
- Findings and specimens sent
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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