CPT® Code 96931

Official Description

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion

Common Language Description

Reflectance confocal microscopy (RCM) is a sophisticated, non-invasive imaging technique utilized for the detailed examination of skin cell populations. This procedure is particularly valuable in the assessment of both benign and malignant tumors, specifically those involving melanocytes and keratinocytes. During the RCM process, a diode laser emits near-infrared light that is precisely focused on a targeted area of the skin. As this light penetrates the cellular structures, it interacts with them, resulting in variations in the refraction indexes and natural light reflections. These interactions are captured and processed using advanced computer software, which reconstructs the data into a two-dimensional grayscale image. The high-resolution images generated through this method allow for a comprehensive histological analysis of the lesion, enabling healthcare professionals to make informed decisions regarding diagnosis and treatment. The CPT® Code 96931 specifically encompasses the complete process of reflectance confocal microscopy for the first lesion, including the image acquisition, interpretation, and the generation of a report. For additional lesions, separate codes such as 96934, 96932, 96933, and 96935 are designated to account for the varying components of the procedure performed on subsequent lesions.

1. Indications

The procedure of reflectance confocal microscopy (RCM) is indicated for the evaluation of various skin lesions, particularly when there is a suspicion of malignancy or when benign tumors need to be differentiated from malignant ones. The following conditions may warrant the use of RCM:

Skin Lesions The procedure is performed to assess skin lesions that may be benign or malignant, particularly those involving melanocytes and keratinocytes.
Suspicion of Melanoma RCM is indicated when there is a clinical suspicion of melanoma, allowing for a non-invasive assessment of the lesion's characteristics.
Keratinocyte Carcinomas The technique is useful in evaluating keratinocyte carcinomas, aiding in the differentiation of various types of skin cancers.

2. Procedure

The procedure of reflectance confocal microscopy involves several key steps that ensure accurate imaging and analysis of skin lesions. The following outlines the procedural steps:

Step 1: Preparation of the Patient The patient is positioned comfortably, and the area of the skin to be examined is cleaned to remove any debris or oils that may interfere with imaging. This preparation is crucial for obtaining clear images.
Step 2: Application of the RCM Device The reflectance confocal microscopy device is then applied to the targeted skin area. The device utilizes a diode laser to emit near-infrared light, which is focused on the skin lesion.
Step 3: Image Acquisition As the laser light penetrates the skin, it interacts with the cellular structures, producing various reflections and refractions. The device captures these interactions, and the data is processed to create high-resolution grayscale images of the cellular architecture.
Step 4: Interpretation of Images The acquired images are analyzed by a trained professional who interprets the microscopic details. This interpretation is essential for identifying the nature of the lesion, whether benign or malignant.
Step 5: Reporting Finally, a comprehensive report is generated, summarizing the findings from the imaging and interpretation. This report is crucial for guiding further clinical decisions and management of the patient.

3. Post-Procedure

After the reflectance confocal microscopy procedure, there are typically no significant post-procedure care requirements, as it is a non-invasive technique. Patients may resume their normal activities immediately following the procedure. However, it is important for healthcare providers to discuss any specific follow-up care or monitoring that may be necessary based on the findings of the RCM. Additionally, the results of the imaging and interpretation should be communicated to the patient, along with any recommended next steps in their care plan.

Short Descr	RCM CELULR SUBCELULR IMG SKN
Medium Descr	RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R 1ST
Long Descr	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion
Status Code	Active Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	4 - Global Test Only Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	02 - Procedure must be performed under the direct supervision of a physician.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Not Billable to the MAC
Berenson-Eggers TOS (BETOS)	T1H - Lab tests - other (non-Medicare fee schedule)
MUE	1

This is a primary code that can be used with these additional add-on codes.

96934

Addon Code MPFS Status: Active Code APC N Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure)

59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GC	This service has been performed in part by a resident under the direction of a teaching physician
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study