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2025 CPT code 60100

Percutaneous core needle biopsy of the thyroid gland.

Medicare allows reporting of 60100 once per lesion or nodule. If multiple nodules are biopsied in the same session, the code should be reported separately for each nodule.Consult the current CPT manual for additional coding guidelines.

Modifiers may be applicable depending on circumstances, including modifiers 22 (increased procedural service), 51 (multiple procedures), 59 (distinct procedural service), and others.

Medical necessity for a percutaneous core needle biopsy of the thyroid is established when there is a palpable or sonographically detected thyroid nodule suspicious for malignancy. Medical necessity is further established if the patient presents with symptoms suggestive of thyroid pathology (e.g., dysphagia, hoarseness, or neck pain).

The physician is responsible for patient preparation, anesthesia administration (if applicable), identification of the target area under imaging guidance, insertion and manipulation of the core needle to obtain tissue samples, and interpretation of imaging results to guide the procedure. The physician also ensures proper specimen handling and transport for pathology review.

IMPORTANT:If imaging guidance is used, report the appropriate imaging guidance code (76942 for ultrasound, 77002 for fluoroscopy, 77012 for CT, or 77021 for MRI) separately.For fine needle aspiration biopsy (FNA), use codes 10004-10012, depending on the number of lesions and imaging guidance used. For evaluation of the fine needle aspirate, use codes 88172 or 88173.

In simple words: The doctor takes a small tissue sample from the thyroid gland using a special needle, often with the help of ultrasound or other imaging. This sample is then examined under a microscope to check for cancer or other problems.

This diagnostic procedure involves removing a tissue sample from the thyroid gland using an automatic, spring-powered core needle.The procedure typically utilizes imaging guidance (ultrasound, fluoroscopy, CT, or MRI—coded separately), where the provider identifies the area to be biopsied, inserts the needle, collects the tissue sample, and sends it for pathological examination. This is performed to determine if a thyroid nodule is benign or malignant.

Example 1: A 45-year-old female presents with a palpable nodule in her right thyroid lobe.Ultrasound guidance is used to perform a percutaneous core needle biopsy of the nodule. Code 60100 is reported along with code 76942 (ultrasound)., A 60-year-old male has a suspicious thyroid nodule identified on a CT scan.A percutaneous core needle biopsy is performed under CT guidance.Code 60100 is reported along with code 77012 (CT)., A 32-year-old female presents with multiple palpable nodules in her left thyroid lobe.Percutaneous core needle biopsies are performed on two distinct nodules under ultrasound guidance. Code 60100 is reported twice along with code 76942 (ultrasound).

* Preoperative diagnosis and indication for biopsy.* Imaging report (if applicable) clearly identifying the target lesion(s).* Detailed description of the procedure, including needle type, imaging guidance used, number of samples taken, and location of sampling within the thyroid gland.* Pathology report with histological findings.

** The use of imaging guidance is strongly recommended for accurate targeting of the lesion(s) and to minimize complications.Accurate documentation is crucial for proper coding and reimbursement.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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