© Copyright 2025 American Medical Association. All rights reserved.
A fine needle aspiration (FNA) biopsy is a minimally invasive procedure used to collect samples from lesions, such as cysts or solid masses, for diagnostic purposes. 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 lesions that may be difficult to access or visualize through standard methods. This includes lesions located in challenging areas such as the abdomen, thorax, or deep-seated nodules in the neck. During a CT-guided FNA biopsy, a radiopaque marker is placed over the lesion site, and the patient undergoes a series of scans to determine the optimal location 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 an antiseptic solution 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 of cells or fluid. The collected specimens are prepared by smearing them onto microscope slides, which are then air-dried, fixed, and stained for microscopic examination. This immediate analysis helps determine whether the samples are adequate or if additional biopsies are required. For billing purposes, CPT® code 10009 is reported for the first lesion biopsied using CT guidance, while 10010 is designated for each additional lesion biopsied in the same session.
© Copyright 2025 Coding Ahead. All rights reserved.
The fine needle aspiration biopsy procedure is indicated for various clinical scenarios, particularly when there is a need to obtain tissue samples from lesions that may be difficult to access or pose a risk if subjected to open biopsy. 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 avoid strenuous activities for a short period following the procedure. The results of the biopsy are typically communicated to the patient within a specified timeframe, depending on the laboratory processing time. Follow-up appointments may be scheduled to discuss the findings and any further necessary actions based on the results.
| Short Descr | FNA BX W/CT GDN EA ADDL | Medium Descr | FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL | Long Descr | Fine needle aspiration biopsy, including CT 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.
| 10009 | Resequenced Code MPFS Status: Active Code APC T ASC G2 Fine needle aspiration biopsy, including CT guidance; first lesion |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | RT | Right side (used to identify procedures performed on the right side of the body) | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2019-01-01 | Added | Added |
Get instant expert-level medical coding assistance.