Please refer to the CPT Assistant below: (A FNA can be utilized to obtain
fluid or tissue)
A biopsy was performed by our radiologist using the fine needle aspiration technique. The intent of the procedure was to obtain a biopsy. Should this be reported using a biopsy code or the fine needle aspiration code?
From a CPT coding perspective, the fine needle aspiration codes (88170, 88171) are intended to report the aspiration of fluid or tissue through a long slender needle, followed by a cytological examination of the cells which are obtained. This is in contrast to a biopsy, where a small piece of tissue is taken and examined for histologic architecture. The method used for obtaining a specimen depends on the clinical situation and clinical factors (eg, suspected diagnosis, location of lesion). The physician should report based on the method used to obtain the specimen.
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