How To Use CPT Code 10021

CPT 10021 is a code for fine needle aspiration biopsy without imaging guidance for the first lesion. This article will cover the description, procedure, qualifying circumstances, when to use, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 10021.

1. What is CPT 10021?

CPT 10021 is a medical billing code used to describe a fine needle aspiration biopsy procedure performed without the use of imaging guidance on the first lesion. This code is part of the Current Procedural Terminology (CPT) system, which is a standardized set of codes used by healthcare providers to report medical procedures and services for billing purposes.

2. 10021 CPT code description

The official description of CPT code 10021 is: “Fine needle aspiration biopsy, without imaging guidance; first lesion.”

3. Procedure

The CPT 10021 procedure involves the following steps:

  1. The provider identifies a suspicious lesion or area of tissue that requires a biopsy.
  2. A specialized needle, typically an 18- to 25-gauge needle with an attached syringe, is inserted into the lesion or tissue.
  3. The provider withdraws cells, tissue, or fluid from the lesion or tissue using the needle and syringe.
  4. Several passes may be made to obtain an adequate specimen.
  5. The aspirate is sent to the pathology lab for analysis.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 10021 services are those with a suspicious lesion or area of tissue that requires a biopsy for diagnostic purposes. This may include patients with palpable masses, cysts, or other abnormal tissue that cannot be accurately diagnosed through other means, such as imaging studies or physical examination alone.

5. When to use CPT code 10021

It is appropriate to bill the 10021 CPT code when a fine needle aspiration biopsy is performed without the use of imaging guidance on the first lesion. This code should be used for the initial lesion biopsied during the procedure. If additional lesions are biopsied, separate codes should be used to report those services.

6. Documentation requirements

To support a claim for CPT 10021, the following information should be documented in the patient’s medical record:

  • Indication for the biopsy, including the presence of a suspicious lesion or area of tissue.
  • Description of the procedure, including the type of needle used, the number of passes made, and the method of specimen collection.
  • Confirmation that the procedure was performed without the use of imaging guidance.
  • Results of the pathology analysis, including a diagnosis or identification of the lesion or tissue.

7. Billing guidelines

When billing for CPT code 10021, it is important to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 10021 include:

  • Report +10004 for each additional lesion biopsied during the same procedure.
  • For FNA of an initial lesion using imaging guidance, see 10005 (ultrasound), 10007 (fluoroscopy), 10009 (CT), and 10011 (MRI) and +10006, +10008, +10010, and +10012 for each additional lesion respectively.
  • Ensure that the documentation requirements listed above are met to support the claim for CPT 10021.

8. Historical information

CPT 10021 was added to the Current Procedural Terminology system on January 1, 2002. The code was changed on January 1, 2019, with the previous descriptor being “Fine needle aspiration; without imaging guidance.”

9. Similar codes to CPT 10021

Five similar codes to CPT 10021 and how they differentiate from CPT 10021 are:

  • CPT 10004: This code is used for each additional lesion biopsied during the same fine needle aspiration procedure without imaging guidance.
  • CPT 10005: This code is used for fine needle aspiration biopsy with ultrasound guidance for the first lesion.
  • CPT 10007: This code is used for fine needle aspiration biopsy with fluoroscopic guidance for the first lesion.
  • CPT 10009: This code is used for fine needle aspiration biopsy with computed tomography (CT) guidance for the first lesion.
  • CPT 10011: This code is used for fine needle aspiration biopsy with magnetic resonance imaging (MRI) guidance for the first lesion.

10. Examples

Here are 10 detailed examples of CPT code 10021 procedures:

  1. A patient presents with a palpable mass in the neck. The provider performs a fine needle aspiration biopsy without imaging guidance and sends the specimen to the pathology lab for analysis.
  2. A patient has a suspicious cyst in the breast. The provider performs a fine needle aspiration biopsy without imaging guidance to collect fluid from the cyst for analysis.
  3. A patient has a palpable mass in the axillary region. The provider performs a fine needle aspiration biopsy without imaging guidance to collect tissue for analysis.
  4. A patient presents with a suspicious nodule in the thyroid. The provider performs a fine needle aspiration biopsy without imaging guidance to collect cells for analysis.
  5. A patient has a palpable mass in the groin. The provider performs a fine needle aspiration biopsy without imaging guidance to collect tissue for analysis.
  6. A patient presents with a suspicious lump in the salivary gland. The provider performs a fine needle aspiration biopsy without imaging guidance to collect cells for analysis.
  7. A patient has a palpable mass in the chest wall. The provider performs a fine needle aspiration biopsy without imaging guidance to collect tissue for analysis.
  8. A patient presents with a suspicious nodule in the lung. The provider performs a fine needle aspiration biopsy without imaging guidance to collect cells for analysis.
  9. A patient has a palpable mass in the abdominal wall. The provider performs a fine needle aspiration biopsy without imaging guidance to collect tissue for analysis.
  10. A patient presents with a suspicious lump in the parotid gland. The provider performs a fine needle aspiration biopsy without imaging guidance to collect cells for analysis.

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