CPT® Code 96934

Official Description

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)

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 varying degrees of refraction 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 skin lesions, facilitating accurate diagnosis and treatment planning. The CPT® code 96934 specifically pertains to the imaging and interpretation of each additional lesion beyond the first, which is covered under code 96931. This structured approach to skin imaging enhances the ability of healthcare professionals to identify and monitor skin conditions effectively.

1. Indications

The procedure of reflectance confocal microscopy (RCM) is indicated for the evaluation of various skin lesions, particularly when there is a need to differentiate between benign and malignant tumors. The following conditions may warrant the use of RCM:

Skin Lesions Assessment of suspicious skin lesions that may require further investigation to determine their nature.
Melanocytic Tumors Evaluation of melanocytic tumors, including melanoma, to ascertain their characteristics and potential malignancy.
Keratinocytic Tumors Investigation of keratinocytic tumors to identify any atypical features that may suggest malignancy.

2. Procedure

The procedure of reflectance confocal microscopy involves several key steps to ensure accurate imaging and analysis of skin lesions. Each step is crucial for obtaining high-quality images and reliable interpretations.

Step 1: Preparation The area of skin to be examined is prepared by cleaning the surface to remove any debris or oils that may interfere with imaging. This ensures that the laser light can penetrate the skin effectively.
Step 2: Image Acquisition A diode laser is then used to emit near-infrared light, which is focused on the targeted skin lesion. As the light interacts with the cellular structures, it captures various reflections and refractions, which are essential for creating detailed images.
Step 3: Image Processing The captured data is processed using specialized computer software that reconstructs the information into a two-dimensional grayscale image. This image provides a detailed view of the cellular and sub-cellular structures within the skin.
Step 4: Interpretation and Reporting The final step involves the interpretation of the images by a qualified healthcare professional. A comprehensive report is generated, detailing the findings and any recommendations for further action or treatment.

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 essential for healthcare providers to communicate any specific follow-up instructions or observations based on the findings from the imaging. If any lesions are identified that require further evaluation or treatment, appropriate referrals or additional diagnostic procedures may be recommended. Continuous monitoring of the skin lesions may also be advised, depending on the results of the RCM analysis.

Short Descr	RCM CELULR SUBCELULR IMG SKN
Medium Descr	RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R ADD
Long Descr	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)
Status Code	Active Code
Global Days	ZZZ - Code Related to Another Service
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 Packaged into APC Rates
Berenson-Eggers TOS (BETOS)	T1H - Lab tests - other (non-Medicare fee schedule)
MUE	2

This is an add-on code that must be used in conjunction with one of these primary codes.

96931

MPFS Status: Active Code APC M Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion

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.
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study