Question: My endocrinologist performed a fine needle aspiration (FNA) to biopsy a nodule on the thyroid. The medical record states that the ultrasound guidance was performed in the radiology suite. Does this mean that I should code only 10021 (Fine needle aspiration; without imaging guidance) and expect the radiologist to report the appropriate radiology code based on the procedure?
Massachusetts Subscriber
Answer: Report fine needle aspiration with codes from the 10021 series. CPT designed these codes to report the technique of FNA, and they are not anatomy-specific. The distinguishing feature for these codes is the imaging guidance. When a physician performs an FNA without imaging guidance, you should report 10021.
However, when imaging guidance is necessary for needle placement (as it was in your case), you should select code 10022 (... with imaging guidance). When physicians perform imaging guidance, codes for radiologic supervision and interpretation also need to be reported, but leave this to the radiology department. The radiologist will report a separate radiology code, such as 76942 (Ultrasonic guidance for needle placement, imaging supervision and interpretation).
