CPT® Code 10004

Add-On Code

Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)

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.