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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 magnetic resonance imaging (MRI) or computed tomography (CT), to accurately locate and target the lesion for sampling. This is crucial for lesions that are difficult to access or localize through standard methods, including those situated in the abdomen, thorax, or deep within the neck. During the FNA biopsy, a radiopaque marker may be placed over the lesion site to assist in imaging. The patient is then scanned in small increments to determine the optimal location for the biopsy. In some instances, intravenous (IV) sedation may be administered to enhance patient comfort. The procedure begins with the preparation of the site using local anesthesia and antiseptic solutions. A coaxial biopsy guide needle is inserted, followed by a confirmation scan to ensure proper placement. A biopsy gun is then 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 onto microscope slides, air-drying, and then fixing and staining for microscopic examination. This immediate analysis helps determine whether the samples are adequate or if additional biopsies are required. For coding purposes, the primary procedure for the first lesion biopsied with CT guidance is reported with code 10009, while code 10010 is used for each additional lesion. For MRI guidance, the first lesion is reported with code 10011, and each additional lesion is reported with code 10012.
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The fine needle aspiration biopsy procedure is indicated for various clinical scenarios where obtaining tissue 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 procedural steps are performed:
After the fine needle aspiration biopsy, the patient may be monitored for a short period to ensure there are no immediate complications, such as bleeding or infection. Instructions regarding care at the biopsy site may be provided, including keeping the area clean and dry. Patients are typically advised to report any unusual symptoms, such as excessive pain, swelling, or signs of infection. The recovery period is generally brief, and most patients can resume normal activities shortly after the procedure, depending on their individual circumstances and the extent of the biopsy performed.
| Short Descr | FNA BX W/MR GDN EA ADDL | Medium Descr | FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL | Long Descr | Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure) | Status Code | Carriers Price the 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.
| 10011 | Resequenced Code MPFS Status: Carrier Priced APC T ASC R2 Fine needle aspiration biopsy, including MR guidance; first lesion |
| XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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. | 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). |
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| 2021-01-01 | Note | Guidelines changed. |
| 2019-01-01 | Added | Added |
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