CPT® Code 10010

Add-On Code

Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure)

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.