From biopsy to localization device to mastectomy, coding for breast procedures can be challenging. This article summarizes the rules related to these services.
Fine needle aspiration of a breast mass, or aspiration of a cyst
Fine needle aspiration (FNA) of a breast mass is reported with codes 10021—10012. CPT® developed new codes for FNA in 2019. These codes are reported when aspiration occurs and the material is sent for pathologic examination.
- There are codes for use without image guidance (10021, +10004), and codes to be used when an FNA is done with imaging guidance, including ultrasound guidance (10005, +10006, with fluoroscopic imaging (10007, +10008).
- And finally, with CT guidance (10009, +10010) and with MR guidance (10011, +10012).
Look carefully as these are out of numeric sequence in the CPT®. There is a CodingIntel article describing them.
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Relevant Search Terms: breast biopsy, excision of breast mass, placement of localization device, CPT® coding for surgeons