CPT® Code 96936

Official Description

Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report 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 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 thorough histological analysis of the lesions present, facilitating accurate diagnosis and treatment planning. The CPT® code 96936 specifically pertains to the interpretation and reporting of RCM findings for each additional lesion examined, following the primary procedure, which is coded separately. This structured approach ensures that healthcare professionals can effectively document and bill for the services rendered during the RCM process.

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 lesions suspected to be melanocytic tumors, including melanoma.
Keratinocytic Tumors Investigation of keratinocyte-derived tumors to ascertain their characteristics and potential malignancy.

2. Procedure

The procedure for reflectance confocal microscopy (RCM) involves several key steps to ensure accurate imaging and analysis of skin lesions. The following outlines the procedural steps:

Step 1: Preparation The patient is prepared for the procedure, which may include cleansing the area of skin to be examined to ensure optimal imaging conditions.
Step 2: Application of RCM The RCM device is positioned over the targeted skin lesion. A diode laser emits near-infrared light, which is directed onto the skin. This light penetrates the skin layers, allowing for the capture of cellular details.
Step 3: Image Acquisition As the light interacts with the skin cells, it generates reflections and refractions that are collected by the RCM device. These data points are then processed to create high-resolution grayscale images of the cellular structures.
Step 4: Interpretation The images obtained are analyzed by a qualified healthcare professional who interprets the findings. This step is crucial for identifying the nature of the lesions and determining the appropriate clinical course of action.
Step 5: Reporting A detailed report is generated based on the interpretation of the images. This report includes findings related to the cellular characteristics of the lesions and any recommendations for further management.

3. Post-Procedure

After the reflectance confocal microscopy procedure, patients may be advised on specific post-procedure care, although the non-invasive nature of RCM typically results in minimal recovery time. Patients can generally resume normal activities immediately following the procedure. However, it is essential for healthcare providers to communicate any specific instructions regarding skin care or follow-up appointments based on the findings from the RCM analysis. Continuous monitoring of the lesions may be recommended, especially if there are indications of malignancy or if further intervention is necessary.

Short Descr	RCM CELULR SUBCELULR IMG SKN
Medium Descr	RCM CELULR & SUBCELULR SKN IMGNG I&R EA ADDL
Long Descr	Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; interpretation and report 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)	2 - Professional 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	09 - Concept does not apply.
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.

96933

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

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.