CPT® Code 10012

Add-On Code

Fine needle aspiration biopsy, including MR 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 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.