2025 CPT code 10010
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Surgical Procedures Surgery Feed
Fine needle aspiration biopsy, each additional lesion with CT guidance.Report separately in addition to the primary procedure code.
Modifier 59 (Distinct procedural service) may be necessary when multiple FNA biopsies are performed on separate lesions using different imaging modalities within the same session.
Medical necessity for an FNA biopsy is established based on clinical findings suggestive of malignancy, such as a palpable mass, abnormal imaging findings, or elevated tumor markers. The decision to perform multiple biopsies on separate lesions is dependent on clinical suspicion and the need for further diagnostic evaluation.
The physician is responsible for performing the FNA biopsy, including the insertion of the needle under CT guidance, obtaining a sufficient sample, and sending the sample to the pathology lab.The pathologist is responsible for the interpretation and reporting of the aspirate.
In simple words: This code means the doctor took extra samples from more than one suspicious area in your body using a thin needle guided by a CT scan during a single visit. This is added to the main code used to bill for the first sample taken.
This CPT code, 10010, represents the performance of a fine needle aspiration (FNA) biopsy on each additional lesion, utilizing computed tomography (CT) guidance.This code is reported in addition to the primary procedure code (e.g., 10009 for the initial lesion with CT guidance) and only when multiple lesions are biopsied during the same session, using the same imaging modality.The procedure involves inserting a fine needle into the lesion under CT guidance, aspirating cells or fluid, and sending the sample for pathological analysis. Multiple passes might be needed for a sufficient sample.
Example 1: A patient presents with multiple suspicious nodules in the thyroid gland.The physician performs an FNA biopsy on the largest nodule (coded as 10009), and then performs FNAs on two additional smaller nodules (coded as 10010 x 2).All biopsies are performed under CT guidance during the same session., A patient has a breast mass and several axillary lymph nodes that are suspicious for malignancy. The physician performs a core needle biopsy of the breast mass and an FNA biopsy of two lymph nodes, all under ultrasound guidance, during one session. The initial FNA (primary code) is reported with its appropriate add-on code for the additional lymph node, using modifier 59., A patient presents with multiple liver lesions detected on CT scan.The physician performs an FNA biopsy on the largest lesion (primary code) and two additional smaller lesions (10010 x 2) using the same CT imaging equipment during the same visit.
Detailed documentation should include the indication for the biopsy, the location and number of lesions biopsied, the imaging guidance used (CT scan), the number of passes of the needle, and the type and amount of tissue or fluid obtained.The pathology report should be included.
** This code is an add-on code, meaning it is reported in addition to the primary procedure code for the initial lesion.Accurate documentation is crucial for proper coding and reimbursement.The use of imaging guidance codes (e.g., 76942, 77002, 77012, 77021) should be carefully considered in conjunction with codes 10004-10012 and 10021, as these may not be reported separately.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: The RVUs for this code will vary based on the geographical location, practice expense, and malpractice insurance costs. Consult the appropriate fee schedule for the specific RVU value.
- Global Days: This code does not have a global surgical period.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not applicable to this code.
- Fee Schedule: Historical fee schedule data can vary widely based on location and payer.Consult historical fee schedules from relevant payers.
- Specialties:Radiology, Surgery, Pathology, Oncology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center