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
Examples
Example 1
A patient presents with a palpable thyroid nodule discovered during a physical examination. The physician performs a fine needle aspiration (FNA) biopsy of the first lesion without imaging guidance in the office to obtain cells for cytologic evaluation. CPT code 10021 is reported.
Example 2
A patient is evaluated for a palpable soft tissue mass in the neck. The physician performs a fine needle aspiration biopsy without ultrasound or other imaging guidance to obtain a tissue sample for diagnosis. The specimen is sent to pathology for cytologic analysis, making CPT code 10021 the appropriate code.
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
