CPT® Code 96935

Official Description

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, 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 near-infrared light emitted from a diode laser 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 thorough histological analysis of the lesions, aiding in the diagnosis and management of skin conditions. The coding structure for RCM includes various CPT® codes that differentiate between the types of procedures performed, such as image acquisition with interpretation and report, image acquisition only, and additional lesions examined. Specifically, CPT® Code 96935 is designated for the image acquisition of each additional lesion, following the primary procedure, which is essential for accurate billing and documentation in clinical practice.

1. Indications

Reflectance confocal microscopy (RCM) is indicated for the evaluation of skin lesions to determine the presence of benign or malignant tumors. The procedure is particularly useful in the following scenarios:

Skin Lesion Assessment The procedure is performed to investigate suspicious skin lesions that may require further analysis to differentiate between benign and malignant conditions.
Melanocyte Tumors RCM is utilized for the examination of tumors involving melanocytes, which are the cells responsible for pigment production in the skin.
Keratinocyte Tumors The technique is also indicated for assessing tumors of keratinocytes, the predominant cell type in the outer layer of the skin.

2. Procedure

The procedure for reflectance confocal microscopy (RCM) involves several key steps to ensure accurate imaging and analysis of skin lesions. Each step is critical for obtaining high-quality images that can be used for diagnostic purposes.

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 essential to ensure clear visualization of the skin structures.
Step 2: Application of the RCM Device The RCM device is then applied to the skin lesion. The device emits near-infrared light, which penetrates the skin and interacts with the cellular structures. The operator must ensure that the device is properly aligned to capture the target area effectively.
Step 3: Image Acquisition As the light passes through the skin, it is reflected back, and the variations in light are captured by the RCM device. The software processes these reflections to create detailed grayscale images of the cellular architecture of the lesion.
Step 4: Documentation of Findings The images obtained are documented for further analysis. If multiple lesions are examined, each additional lesion is recorded separately, following the guidelines for coding and billing.

3. Post-Procedure

After the reflectance confocal microscopy procedure, there are no specific post-procedure care requirements as it is a non-invasive technique. Patients can typically resume their normal activities immediately following the procedure. However, it is essential for healthcare providers to review the images and findings with the patient, discussing any necessary follow-up actions or further diagnostic steps based on the results obtained. Documentation of the procedure and findings is crucial for accurate coding and billing, particularly when multiple lesions are involved, as this will impact the selection of appropriate CPT® codes for reimbursement.

Short Descr	RCM CELULR SUBCELULR IMG SKN
Medium Descr	RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ EA ADDL
Long Descr	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, 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)	3 - Technical Component 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.

96932

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