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The procedure described by CPT® Code 10021 refers to a fine needle aspiration biopsy (FNA) performed without the use of imaging guidance, specifically for the first lesion. This minimally invasive technique utilizes a fine gauge needle, typically ranging from 22 to 25-gauge, along with a syringe to extract fluid or cellular material from a lump, lesion, or cyst. The primary objective of an FNA biopsy is to obtain a sample of tissue for diagnostic purposes, which can help in identifying the nature of the lesion, whether benign or malignant. During the procedure, the physician first cleanses the biopsy site to minimize the risk of infection. The physician then locates the target lesion through palpation, ensuring accurate needle placement. Once the needle is inserted into the mass, a vacuum is created, and the physician performs multiple in-and-out motions with the needle to collect an adequate sample. It is common for several insertions to be necessary to ensure sufficient tissue is obtained for analysis. After the sample is collected, it is prepared by smearing it onto a microscope slide, which is then air-dried and fixed using either a spray or immersion in a liquid solution. The fixed samples are subsequently stained and examined under a microscope by a pathologist for diagnostic evaluation. Notably, FNA biopsies do not require stitches and are typically conducted on an outpatient basis, allowing many patients to return to their normal activities on the same day. For billing purposes, CPT® Code 10021 should be reported for the first lesion biopsied using this technique without imaging guidance, while CPT® Code 10004 is designated for each additional lesion biopsied in a similar manner.
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The fine needle aspiration biopsy (FNA) procedure indicated by CPT® Code 10021 is typically performed for various clinical scenarios where tissue sampling is necessary. The following are common indications for this procedure:
The fine needle aspiration biopsy procedure involves several key steps to ensure accurate sampling of the target lesion. The following outlines the procedural steps as described:
After the fine needle aspiration biopsy is completed, the patient typically receives a small bandage over the biopsy site to protect it. Since this procedure is minimally invasive, it does not require stitches, and patients are usually able to resume their normal activities on the same day. However, it is important for patients to monitor the biopsy site for any signs of complications, such as excessive bleeding or infection. Follow-up appointments may be scheduled to discuss the results of the biopsy and any further management that may be necessary based on the findings.
| Short Descr | FNA BX W/O IMG GDN 1ST LES | Medium Descr | FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION | Long Descr | Fine needle aspiration biopsy, without imaging 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 | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6D - Minor procedures - other (non-Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 173 - Other diagnostic procedures on skin and subcutaneous tissue |
This is a primary code that can be used with these additional add-on codes.
| 10004 | Add-on Code Resequenced Code MPFS Status: Active Code APC N ASC N1 Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure) |
| 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). | 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. | 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) | 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. | 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). | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | CR | Catastrophe/disaster related | E1 | Upper left, eyelid | E2 | Lower left, eyelid | E4 | Lower right, eyelid | F2 | Left hand, third digit | F3 | Left hand, fourth digit | F5 | Right hand, thumb | F6 | Right hand, second digit | F8 | Right hand, fourth digit | FA | Left hand, thumb | GA | Waiver of liability statement issued as required by payer policy, individual case | 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 | PD | Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days | 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 | T1 | Left foot, second digit | T2 | Left foot, third digit | T3 | Left foot, fourth digit | T5 | Right foot, great toe | T6 | Right foot, second digit | T7 | Right foot, third digit | T9 | Right foot, fifth digit | TA | Left foot, great toe | 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 | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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 | Changed | Description Changed |
| 2002-01-01 | Added | First appearance in code book in 2002. |