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A fine needle aspiration (FNA) biopsy is a minimally invasive procedure used to collect samples from lesions, which may be cysts or solid masses. This technique is particularly beneficial when traditional open biopsy methods pose risks, such as disrupting surgical planes or causing tumor seeding, especially in cases involving previously treated or irradiated lesions. The procedure utilizes imaging guidance, specifically computed tomography (CT) or magnetic resonance imaging (MRI), to accurately locate and target the lesion for sampling. This is crucial for lesions that are difficult to access or localize through standard methods, such as those found in the abdomen, thorax, or deep-seated areas like the neck. During a CT-guided FNA biopsy, a radiopaque marker is placed over the lesion, and the patient undergoes a series of scans to determine the optimal site for the biopsy. In some instances, intravenous (IV) sedation may be administered to enhance patient comfort. The biopsy site is then prepared using local anesthesia and antiseptic solutions to minimize the risk of infection. A coaxial biopsy guide needle is inserted, followed by a confirmation scan to ensure proper placement. Subsequently, a biopsy gun is attached to the guide needle, which is activated to penetrate the mass and aspirate the necessary sample cells or fluid. The collected specimens are prepared by smearing onto microscope slides, air-dried, fixed, and stained for microscopic examination. This immediate analysis helps determine whether the samples are adequate or if additional biopsies are required. The CPT® code 10009 is designated for the first lesion biopsied using FNA with CT guidance, while additional lesions are coded separately with 10010. For MRI guidance, the first lesion is reported with 10011, and subsequent lesions with 10012.
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The fine needle aspiration biopsy (FNA) procedure is indicated for various clinical scenarios where obtaining tissue or fluid samples is necessary for diagnosis. The following conditions may warrant the use of this procedure:
The fine needle aspiration biopsy procedure involves several critical steps to ensure accurate sampling of the targeted lesion. The following outlines the procedural steps:
After the fine needle aspiration biopsy, patients may experience some discomfort or bruising at the biopsy site, which typically resolves within a few days. It is essential to monitor the site for any signs of infection or complications. Patients are usually advised to follow up with their healthcare provider to discuss the results of the biopsy and any further management based on the findings. The immediate analysis of the specimens helps guide the need for additional biopsies if the initial samples are deemed insufficient.
| Short Descr | FNA BX W/CT GDN 1ST LES | Medium Descr | FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION | Long Descr | Fine needle aspiration biopsy, including CT guidance; first lesion | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard 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 | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
This is a primary code that can be used with these additional add-on codes.
| 10010 | Add-on Code Resequenced Code MPFS Status: Active Code APC N ASC N1 Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure) |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 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. | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | MG | The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2019-01-01 | Added | Added |
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