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10021

Fine Needle Aspiration Biopsy Without Imaging Guidance

Code Description

CPT code 10021 is used to report a fine needle aspiration (FNA) biopsy performed without imaging guidance. During the procedure, a healthcare provider inserts a thin needle into a lesion, mass, or suspicious area to collect cells for diagnostic examination.

The collected sample is typically sent to a pathology laboratory for evaluation. CPT 10021 is reported only when imaging guidance is not used during the aspiration.

When to Use 10021

Common examples include:

  • palpable thyroid nodules

  • superficial soft tissue masses

  • enlarged lymph nodes

  • breast lesions that can be identified without imaging

Documentation Requirements

Documentation should include:

  • location of the lesion

  • indication for the biopsy

  • aspiration technique performed

  • specimen collection details

  • patient tolerance of the procedure

Common Billing Mistakes

Common billing mistakes include:

  • reporting 10021 when imaging guidance was used

  • insufficient procedure documentation

  • incorrect lesion identification

  • billing multiple aspiration codes incorrectly

Related CPT Codes

10022- Fine Needle Aspiration Biopsy With Imaging Guidance

11102- Tangential Skin Biopsy

11400- Excision of Benign Lesion

FAQ
What is CPT code 10021?

CPT 10021 describes a fine needle aspiration biopsy performed without imaging guidance.

Does CPT 10021 include ultrasound guidance?

No. If imaging guidance is used, a different CPT code may apply.

What type of specimen is collected?

Cells or fluid are collected through a thin needle for diagnostic evaluation.

Is CPT 10021 considered a biopsy?

Yes. Fine needle aspiration is a biopsy technique used to obtain diagnostic tissue samples.

Procedure Type

Biopsy

Imaging Guidance

MDM Level

Not Included

High