2025 CPT code 10009
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Surgical Procedures Surgery Feed
Fine needle aspiration biopsy, including CT guidance; first lesion.
Modifier 59 (Distinct procedural service) may be applied when multiple FNA biopsies are performed on separate lesions, same session, same day, using different imaging modalities.Other modifiers might apply depending on the circumstances. Consult the CPT manual.
The medical necessity for a CT-guided FNA biopsy is established when imaging reveals a suspicious lesion (mass, nodule) requiring further evaluation to determine the nature of the lesion (benign, malignant, inflammatory). The procedure is considered medically necessary to diagnose and guide treatment planning.
The physician is responsible for selecting the appropriate site for biopsy, inserting the needle under CT guidance, obtaining an adequate tissue sample for cytologic analysis, and interpreting the results in the context of the patient's clinical presentation. The pathologist is responsible for analyzing the aspirated sample and providing a detailed cytologic report.
In simple words: This code describes a procedure where a doctor uses a very thin needle to take a small sample of cells from an area of concern in the body. The procedure is guided by a CT scan, a type of imaging test. The sample is then examined under a microscope to help diagnose a condition.
This CPT code (10009) represents a fine needle aspiration (FNA) biopsy of the first lesion, guided by computed tomography (CT) imaging.The procedure involves using a thin needle to aspirate cells or tissue from a suspicious lesion under CT guidance for cytological evaluation.This code is reported only once for the initial lesion biopsied in a single session. Additional lesions biopsied during the same session require additional codes (e.g., +10010 for additional lesions with CT guidance).
Example 1: A 55-year-old female presents with a palpable mass in her right breast.A CT-guided FNA biopsy of the mass is performed, and code 10009 is reported for the initial lesion. Pathology reveals malignant cells., A 60-year-old male presents with a suspicious pulmonary nodule detected on a CT scan.A CT-guided FNA biopsy of the nodule is performed, code 10009 is used.Additional lesions are found and biopsied, requiring additional codes., A 30-year-old female with a thyroid nodule undergoes an ultrasound-guided FNA biopsy of the initial lesion. However, during the procedure, the physician needs to utilize CT guidance for better visualization, making code 10009 appropriate.
Complete patient history and physical examination;radiology reports of the CT scan including images demonstrating the location of the lesion and needle placement; pathology report with cytologic interpretation; operative report detailing the procedure and the number of passes.
** This code is specifically for the initial lesion biopsied.Additional codes are required for subsequent lesions biopsied in the same session.Always refer to the most current CPT guidelines for accurate coding.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Radiology, Surgery, Oncology, Pathology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center