2025 CPT code 10011
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Surgical Procedures Surgery Feed
Fine needle aspiration biopsy, including MR guidance; first lesion.
Modifier 59 (Distinct procedural service) may be appended when multiple FNA biopsies are performed on separate lesions in the same session using different imaging guidance modalities.
Medical necessity for an MRI-guided FNA biopsy is established when imaging studies reveal a suspicious mass or lesion that requires cytological evaluation to differentiate between benign and malignant conditions, or to guide further management.
The physician's responsibility includes preparing the patient, selecting the appropriate needle size, utilizing MRI guidance for accurate needle placement, aspirating the sample, and sending the aspirate to the pathology lab for analysis. The physician must also document the procedure thoroughly.
In simple words: This code describes a test where a doctor uses a very thin needle to take a small sample of cells from a suspicious area in your body, guided by an MRI scan. The sample is then sent to a lab to help determine if there's a problem.
This CPT code 10011 represents a fine needle aspiration (FNA) biopsy of the first lesion performed under magnetic resonance imaging (MRI) guidance.The procedure involves inserting a thin needle into a suspicious lesion to collect cells or fluid for cytological examination.This is a minimally invasive diagnostic procedure to evaluate a mass or abnormality.
Example 1: A patient presents with a suspicious breast mass detected on mammography. An MRI-guided FNA biopsy (10011) is performed to obtain cells for cytological analysis to determine if the mass is benign or malignant., A patient presents with a thyroid nodule detected on ultrasound.An MRI-guided FNA biopsy is performed to evaluate the nodule for malignancy, and the obtained cells are sent for pathology review., A patient has a lung mass visualized on CT scan. The radiologist performs MRI-guided FNA (10011) for diagnostic purposes.The results of the cytology report will guide further management.
* Detailed history and physical examination* Imaging studies (MRI, previous imaging if any) showing the lesion location.* Indication for performing the FNA biopsy.* Description of the procedure, including needle gauge, number of passes and volume of fluid or tissue aspirated* Pathology report with cytological results.* Any complications encountered during or after the procedure.
** The selection of the appropriate code depends on the number of lesions, the imaging guidance used, and whether other procedures (such as core needle biopsy) are performed in the same session.Always refer to the most current CPT manual for coding guidelines.
- 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