2025 CPT code 10004
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Surgical Procedures Surgery Feed
Fine needle aspiration biopsy, each additional lesion (without imaging guidance).
Modifier 59 (Distinct procedural service) may be appropriate when the additional lesions are in different anatomical locations or different organs, or when different imaging modalities are used for each additional lesion.
Medical necessity for FNA biopsy is established based on clinical findings suggesting malignancy or other pathology requiring cytological or histological evaluation of the lesion(s).
The physician's responsibility includes performing the fine needle aspiration biopsy, obtaining an adequate specimen, and sending the sample for pathological analysis.Appropriate patient preparation and local anesthesia are also part of the procedure.
In simple words: This code is for extra biopsies done using a thin needle to collect a sample of cells.It's only used if the doctor already did one biopsy, and needs to do more on other areas at the same appointment. It's not used if imaging (like an ultrasound) is used to help guide the biopsy.
This CPT code, 10004, reports each additional lesion biopsied using fine needle aspiration (FNA) without imaging guidance.It is an add-on code and must be reported in conjunction with the primary procedure code 10021 (Fine needle aspiration biopsy, without imaging guidance) for the initial lesion.The code is used when multiple lesions are sampled during the same session using the same imaging modality (or no imaging guidance at all).It is not reported separately with imaging guidance codes (e.g., 76942, 77002, 77012, 77021).
Example 1: A patient presents with a palpable breast mass.The physician performs an FNA biopsy of the initial mass (10021).During the same session, two additional suspicious lesions are identified and biopsied.Codes 10004 x 2 are added to 10021 to reflect the additional biopsies., A patient has a thyroid nodule. The physician performs an FNA biopsy of the nodule (10021) with ultrasound guidance (10005). Two additional nodules are detected and an FNA is performed on each using the same ultrasound guidance. Code 10006 is added twice., A patient has multiple suspicious lymph nodes in the neck.The physician performs FNA biopsy of the largest node (10021) without imaging guidance. They perform FNAs of two other nodes (10004 x 2) during the same session without imaging guidance.
Complete medical record should document the number and location of lesions sampled, technique used (FNA), imaging guidance used (if any), and the date and time of the procedure.Pathology reports should confirm adequacy of the specimen.
** This code is specifically for additional lesions biopsied during the *same* session.If multiple sessions are involved, code each session separately.Always check for any payer-specific coding guidelines or local coverage determinations (LCDs) that may affect reimbursement.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: Information not available in provided sources. Refer to CMS guidelines for current RVUs.
- Global Days: Not applicable; this is not a surgical procedure with a global period.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Information not available in provided sources. Consult fee schedules and local payers for historical and current data.
- Specialties:Surgery, Pathology, Radiology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center