CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

Coding for breast procedures: biopsy, localization devices, and surgery

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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

- Betsy Nicoletti
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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.