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BETA v.3.0

2025 CPT code 10012

Fine needle aspiration biopsy, each additional lesion under MR imaging guidance.

Codes 10004-10012, 10021 are reported once per lesion sampled in a single session. When more than one FNA biopsy is performed on separate lesions at the same session, same day, same imaging modality, use the appropriate imaging modality add-on code for the second and subsequent lesion(s). When more than one FNA biopsy is performed on separate lesions, same session, same day, using different imaging modalities, report the corresponding primary code with modifier 59 for each additional imaging modality and corresponding add-on codes for subsequent lesions sampled.If FNA and core needle biopsy are performed on the same lesion, do not separately report the imaging guidance for the core needle biopsy. If performed on separate lesions, imaging guidance may be reported separately with modifier 59.

Modifier 59 (Distinct Procedural Service) may be applied when performing FNA on separate lesions with different imaging modalities during the same session.

Medical necessity is established by the presence of suspicious lesions requiring further diagnostic evaluation to guide treatment decisions. The clinical indication for FNA should be documented in the medical record.

The physician inserts a needle under MRI guidance into additional suspicious lesions, withdraws cells/tissue/fluid for lab analysis, and sends the aspirate to pathology.

IMPORTANT:For FNA of an initial lesion using other imaging guidance, see 10005 (ultrasound), 10007 (fluoroscopy), and 10009 (CT) and +10006, +10008, +10010 for each additional lesion respectively. For FNA without imaging guidance, report 10021 for the initial lesion and +10004 for each additional lesion.For evaluation of fine needle aspirate, see 88172, 88173, 88177. For percutaneous needle biopsy (other than FNA), see codes 19081-19086 (breast), 20206 (muscle), 32400 (pleura), 32408 (lung or mediastinum), 42400 (salivary gland), 47000 (liver), 48102 (pancreas), 49180 (abdominal or retroperitoneal mass), 50200 (kidney), 54500 (testis), 54800 (epididymis), 60100 (thyroid), 62267 (nucleus pulposus, intervertebral disc, or paravertebral tissue), 62269 (spinal cord). For percutaneous image-guided fluid collection drainage by catheter of soft tissue, use 10030.

In simple words: This code is for extra lesions biopsied using an MRI machine after an initial biopsy.A thin needle is used to take a tiny sample from the suspicious area to check for disease under the guidance of an MRI machine. This code is used only if more than one sample is taken from different areas during the same appointment using the same MRI.

This code reports each additional lesion biopsied using magnetic resonance imaging (MRI) guidance, in addition to the primary procedure code (10011).A fine needle aspiration (FNA) biopsy is performed using a fine needle to collect a sample for cytological examination.This code is used when multiple lesions are sampled during the same session using the same MRI guidance. The procedure involves inserting a needle into each lesion under MRI guidance to collect cells, tissue, or fluid for laboratory analysis.

Example 1: A patient presents with multiple suspicious thyroid nodules.An FNA biopsy is performed on the largest nodule (coded 10011), and additional FNAs are performed on two smaller nodules under MRI guidance (coded 10012 x 2). , A patient presents with a breast mass and suspicious axillary lymph nodes.An FNA of the breast mass is performed (coded 10011), and FNAs are performed on two separate axillary lymph nodes under MRI guidance (coded 10012 x 2)., A patient with lung cancer has multiple suspicious mediastinal lymph nodes.An initial FNA of one node is performed (10011), and additional FNAs are performed on three additional nodes under MRI guidance (10012 x 3).

Detailed operative report specifying the number of lesions biopsied, imaging guidance used (MRI), and the location of each lesion. Pathology report confirming the adequacy of the aspirate for diagnosis.

** This code is an add-on code, and must be reported in addition to the primary procedure code (10011).

  • Revenue Code: P6C (Medicare Fee Schedule: MINOR PROCEDURES - OTHER)
  • Payment Status: Active
  • Modifier TC rule: Not applicable.
  • Specialties:Radiology, Oncology, Surgery, Pathology
  • Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center
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