CPT Code 10021: Fine Needle Aspiration (FNA) Biopsy, Without Imaging Guidance

No, CPT code 10021 is reported once per separately identifiable lesion, regardless of the number of needle passes performed during the procedure. According to CMS guidelines, the unit of service for fine needle aspiration biopsy codes (including 10021) is the lesion itself, not the number of passes or specimens obtained.

If imaging guidance was used during the fine needle aspiration procedure but not documented in the medical record, CPT code 10021 should not be reported. Accurate coding requires clear documentation of whether imaging guidance was utilized; if imaging was employed, the appropriate imaging-guided FNA codes (such as 10005 for ultrasound guidance) must be reported instead to ensure compliance and proper reimbursement.

Yes, local anesthesia is considered an integral part of the fine needle aspiration procedure and is included in CPT code 10021. It should not be reported separately, as the use of local anesthesia is bundled into the procedure code and does not warrant additional billing.