2025 CPT code 10021
(Active) Effective Date: N/A Revision Date: N/A Surgery - General Surgical Procedures Feed
Fine needle aspiration biopsy, without imaging guidance; first lesion.
Modifier 59 may be used to indicate a distinct procedural service.
Medical necessity for this procedure should be clearly documented, including the reason for the biopsy (e.g., suspicious lump, abnormal imaging findings). The documentation should support the need for the procedure to evaluate the lesion and rule out or confirm a diagnosis.
In simple words: A fine needle aspiration biopsy is a procedure where a thin needle is used to collect a sample of cells or fluid from a lump or abnormal area.The sample is then sent to a lab to be examined under a microscope. This helps doctors figure out what's going on. This code is for the first area sampled during the procedure. If more areas are sampled, a different code is also used.
This code represents a fine needle aspiration (FNA) biopsy performed without imaging guidance on the first lesion.A fine needle aspiration biopsy involves using a thin needle to collect cells or fluid from a suspicious area.The collected sample is then examined under a microscope to help diagnose various conditions. This code is specifically for the initial lesion biopsied during a single session.If additional lesions are biopsied during the same session, add-on code 10004 should be used for each additional lesion.
Example 1: A patient presents with a palpable lump in the neck.The physician performs an FNA biopsy without imaging guidance to obtain a sample for diagnostic purposes. Code 10021 is reported., A patient has two palpable breast lumps. The physician performs FNA biopsies on both lesions. Code 10021 is reported for the first lesion and 10004 is reported for the second lesion., A patient has a palpable lymph node in the groin. An FNA biopsy is performed without imaging guidance. During the same encounter, the physician also performs an incision and drainage of an abscess on the patient's arm.Code 10021 is reported for the FNA and the appropriate code for the incision and drainage is reported separately.
Documentation should include the location of the lesion, the method of biopsy (FNA), a description of the sample obtained, and the clinical indication for the procedure.
- Specialties:Many medical specialties can utilize FNA biopsy, including but not limited to: surgery, radiology, internal medicine, oncology, pathology, endocrinology, and dermatology.
- Place of Service:This procedure can be performed in various settings, including physician offices, outpatient clinics, hospitals (inpatient or outpatient), and ambulatory surgical centers.