Summary & Overview
CPT 10009: CT-Guided Fine Needle Aspiration, First Lesion
CPT code 10009 covers CT-guided fine needle aspiration (FNA) for diagnostic sampling of tissue, cysts, or masses and is reported for the first lesion biopsied. This code matters nationally because image-guided percutaneous aspiration is a common minimally invasive diagnostic procedure that influences subsequent care pathways, including definitive diagnosis, staging, and treatment planning. Payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find a concise clinical context for CPT code 10009, including the procedural setting and typical clinical indications. The publication summarizes payer coverage considerations and common modifier usage patterns where available, highlights national benchmarks for utilization and reimbursement trends when present, and summarizes policy updates relevant to image-guided percutaneous biopsies. The content aims to support coders, billing professionals, and policy analysts by clarifying what CPT code 10009 represents, where it is performed, and what to expect in payer coverage and claims reporting. Data not available in the input is noted explicitly where applicable.
Billing Code Overview
CPT code 10009 describes a fine needle aspiration (FNA) performed under CT imaging guidance. The procedure involves using a specialized needle and syringe to collect a diagnostic specimen from tissue, a cyst, or a mass. Report this code for the first lesion biopsied when CT guidance is used.
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Service type: Image‑guided diagnostic percutaneous biopsy (fine needle aspiration)
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Typical site of service: Radiology suite or hospital outpatient department with CT imaging capability; may also be performed in ambulatory surgical centers with CT guidance
Clinical & Coding Specifications
Clinical Context
A 58-year-old patient presents with a 2.5 cm peripheral pulmonary nodule identified on chest CT during evaluation for persistent cough. The referring pulmonologist requests tissue diagnosis. The patient is scheduled to undergo a CT-guided fine needle aspiration (FNA) of the lung lesion. On the day of service, the interventional radiology team performs pre-procedure consent and targeted imaging localization. Under CT imaging guidance, the radiologist advances a fine needle into the lesion, aspirates cellular material for cytology, and obtains multiple passes as needed for diagnostic yield. Specimens are placed in appropriate transport media and sent to pathology; the provider documents lesion location, number of passes, needle size, patient tolerance, and any immediate complications. Billing reports 10009 for the first lesion sampled. Typical site of service is an outpatient radiology suite, hospital outpatient department, or ambulatory surgery center depending on facility resources and patient status. The service type is image-guided diagnostic percutaneous aspiration.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the physician interpretation/technical reading is billed separately from the facility/technical component. |
50 | Bilateral procedure | Use when the same procedure is performed on bilateral anatomic sites and payer requires a bilateral modifier. |
51 | Multiple procedures | Use when multiple distinct procedures are performed the same day in addition to the FNA. |
52 | Reduced services | Use when the procedure is partially reduced or not completed as planned. |
53 | Discontinued procedure | Use when the procedure is started but terminated due to extenuating circumstances or the patient’s condition. |
59 | Distinct procedural service | Use to indicate a distinct procedural service separate from other procedures on the same day (use with caution per payer rules). |
62 | Two surgeons | Use when two surgeons from different specialties perform distinct parts of the same procedure. |
76 | Repeat procedure by same physician | Data not available in the input. |
78 | Return to operating room for a related procedure during the global period | Use if the patient requires an immediate return to the OR for a related complication. |
79 | Unrelated procedure or service by the same physician during the postoperative period | Data not available in the input. |
73 | Discontinued outpatient hospital/ambulatory surgery center procedure prior to anesthesia | Use when procedure is cancelled after patient entry but before anesthesia or sedation. |
22 | Increased procedural services | Use when work required to perform the procedure is substantially greater than typically required. |
52 | Reduced services | Use when service is partially reduced or not completed as planned. |
59 | Distinct procedural service | Use to indicate a distinct procedural service separate from other services performed on the same day. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 207R00000X | Radiology | Interventional radiologists commonly perform CT-guided FNAs. |
| 2085R0200X | Diagnostic Radiology | Diagnostic radiologists with procedural skills perform image-guided aspirations. |
| 207L00000X | Pulmonary Disease | Pulmonologists may request or perform percutaneous lung biopsies in coordination with radiology. |
| 163W00000X | Pathology | Pathologists process and interpret cytology specimens obtained from the FNA. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
R91.8 | Other nonspecific abnormal finding of lung field | Common indication for image-guided FNA of an indeterminate pulmonary nodule. |
R91.1 | Solitary pulmonary nodule | Frequently sampled via CT-guided FNA to obtain cytology for diagnosis. |
C34.90 | Malignant neoplasm of unspecified part of unspecified bronchus or lung | Suspected primary lung malignancy prompting tissue sampling with FNA. |
D49.1 | Neoplasm of uncertain behavior of respiratory and intrathoracic organs | Used when the lesion’s behavior is uncertain and tissue diagnosis is required. |
J98.4 | Other disorders of lung | Applicable for focal lung abnormalities requiring aspiration to evaluate for infectious or inflammatory causes. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
10004 | Fine needle aspiration; with imaging guidance (e.g., ultrasound, CT) — first lesion | An older or alternative code for percutaneous FNA with imaging guidance; may be reported in some coding contexts for certain payers. |
77012 | CT guidance for needle placement (eg, biopsy, aspiration, injection), radiological supervision and interpretation | Reported when CT imaging guidance is billed separately for the needle placement component supporting 10009. |
88172 | Cytopathology, immunocytochemistry, interpretation and report | Billed by the laboratory/pathologist for on-site adequacy evaluation or interpretation of cytology specimens obtained during FNA. |
76536 | Ultrasound guidance for needle placement, imaging supervision and interpretation | Billed instead of CT guidance when ultrasound is used to guide the FNA rather than CT. |
76942 | Ultrasonic guidance for needle placement (during biopsy, aspiration, injection, localization device placement, or therapeutic injection) | Used when real-time ultrasound guidance is employed for needle localization during aspiration. |