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The CPT® Code 10004 refers to a fine needle aspiration biopsy (FNA) performed without imaging guidance for each additional lesion. This procedure involves the use of a fine gauge needle, typically 22- or 25-gauge, along with a syringe to extract fluid from a lump, lesion, or cyst, or to collect clusters of cells from a solid mass. The process begins with the cleansing of the biopsy site, followed by the physician locating the lump through palpation. The needle is then guided into the target area. Once the needle is positioned within the mass, a vacuum is created, and the physician performs multiple in-and-out motions with the needle to ensure that an adequate tissue sample is obtained. It is common for several needle insertions to be necessary to collect sufficient material for analysis. After the samples are collected, they are prepared by smearing onto a microscope slide, allowed to air dry, and then fixed either by spraying or immersion in a liquid. The fixed smears are subsequently stained and examined by a pathologist under a microscope for diagnostic purposes. Notably, FNA does not require stitches and is typically conducted on an outpatient basis, allowing many patients to return to their normal activities on the same day. For billing purposes, code 10021 should be reported for the first lesion biopsied using FNA without imaging guidance, while code 10004 is designated for each additional lesion biopsied in the same manner.
© Copyright 2025 Coding Ahead. All rights reserved.
The fine needle aspiration biopsy (FNA) procedure, represented by CPT® Code 10004, is indicated for the evaluation of various lesions, lumps, or cysts that require cytological analysis. This procedure is typically performed when there is a need to obtain a sample from a solid mass or fluid-filled structure for diagnostic purposes. The indications for performing an FNA may include, but are not limited to, the following:
The procedure for fine needle aspiration biopsy (FNA) as described by CPT® Code 10004 involves several key steps to ensure accurate sampling of the lesion. The following procedural steps are typically followed:
After the fine needle aspiration biopsy is completed, the patient typically receives a small bandage over the biopsy site to protect it. The procedure is generally well-tolerated, and most patients can resume their normal activities on the same day. There is usually minimal discomfort associated with the procedure, and stitches are not required. Patients are advised to monitor the biopsy site for any signs of complications, such as excessive bleeding or infection, and to follow up with their healthcare provider if any concerns arise.
| Short Descr | FNA BX W/O IMG GDN EA ADDL | Medium Descr | FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL | Long Descr | Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure) | Status Code | Active Code | Global Days | ZZZ - Code Related to Another Service | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Items and Services Packaged into APC Rates | ASC Payment Indicator | Packaged service/item; no separate payment made. | Berenson-Eggers TOS (BETOS) | none | MUE | 3 |
This is an add-on code that must be used in conjunction with one of these primary codes.
| 10021 | MPFS Status: Active Code APC T ASC P3 CPT Assistant Article Fine needle aspiration biopsy, without imaging guidance; first lesion |
| X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | T9 | Right foot, fifth digit | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2019-01-01 | Added | Added |