The document outlines the differences between thyroid fine needle aspiration (FNA) and thyroid biopsy, detailing the appropriate CPT code selection based on physician documentation. It emphasizes the importance of clear terminology to prevent coding confusion and provides specific guidelines for coding these procedures. Additionally, it discusses a case example of ultrasound-guided thyroid biopsy to illustrate proper documentation and coding practices.

1. THYROID FINE NEEDLE ASPIRATION vs THYROID BIOPSY
Quick Look:
• Explain the variances between Thyroid Nodule FNA and Thyroid Biopsy
• CPT code choice 10022 or 60100
• Report example of conflicting verbiage
Selecting the correct CPT code choice when reviewing documentation for biopsies and FNA’s are
dependent on the description provided by the physician. If the documentation supports the verbiage of
a biopsy, we will code 60100. If it supports an aspiration, we will assign 10022. Often times the
radiologist will use the terms FNA and biopsy interchangeably when reporting these services. Due to the
different CPT code choices, conflicting documentation can make code assignment difficult for the coder.
Though the basic rules apply to all biopsies and FNA’s, we typically experience the biggest problem with
thyroid procedures. In an effort to improve documentation and streamline the code choice, I am
supplying coding guidelines that apply to these procedures.
FNA Thyroid biopsy
10022 ~ Fine needle aspiration with imaging
guidance 60100 ~ Biopsy thyroid, percutaneous core needle
A needle core biopsy is most often performed using a large-
FNA is typically performed with a small-gauge needle gauge cutting needle
FNA's are routinely sent to pathology for cytology Biopsies are sent to pathology for histology
Cytology is often immediately available for
interpretation Histology is processed overnight
FNA can be reported once for each lesion that is
aspirated Needle core biopsy codes are reported once per lesion
Multiple passes with the needle into the same lesion If multiple specimens are taken from the same lesion, only
is considered to be a single FNA one biopsy procedure should be reported
Additional coding information:
• The coder is instructed NOT to use the size of the needle to distinguish between needle core biopsy
and FNA
• According to CPT, the imaging guidance code should be reported once for each lesion or area
• Medicare allows only one unit of service for the guidance regardless of the number of needle
placements performed
• Codes for both a biopsy and a needle aspiration cannot be billed together at the same session unless
documentation supports inadequate specimen sampling by pathology with one technique (usually
the FNA) requiring the other technique (usually the core biopsy) to obtain adequate material.
• If documentation is unclear, the radiologist needs to be asked to clarify the technique in an
addendum
T. Galan -1- Thyroid FNA vs Biopsy
HIS-South, Radiology Division February 3, 2011

2. CONFLICTING REPORT EXAMPLE
Ultrasound guided thyroid biopsy.
History: Thyroid nodule.
Comparison: None.
Findings:
There are two large nodules that are heterogeneous and solid in the left thyroid lobe. Physician orders
state to biopsy the larger lower pole nodule in the left thyroid lobe. The risks and benefits of the
procedure including, infection, bleeding, injury to surrounding structures was discussed with the patient.
The patient gave informed consent. A timeout was performed to verify the site of procedure, type of
procedure and patient identification. The patient was prepped and draped in a sterile manner. 1%
Lidocaine was used for local anesthesia. Three samples of the lower pole large solid 2.3 cm nodule was
obtained by ultrasound guidance using a 25-gauge needle. These 3 fine-needle aspirates were
considered adequate by pathology at the bedside. No immediate complications.
Impression:
Successful fine needle aspiration of lower pole solid left thyroid lobe nodule.
T. Galan -2- Thyroid FNA vs Biopsy
HIS-South, Radiology Division February 3, 2011