2025 CPT code 96931
(Active) Effective Date: N/A Revision Date: N/A Dermatology - Special Dermatological Procedures Medicine Services and Procedures Feed
Reflectance confocal microscopy (RCM) for cellular and subcellular imaging of skin; image acquisition, interpretation, and report for the first lesion.
Modifiers 52 (reduced services), 59 (distinct procedural service), 76 (repeat procedure), 77 (repeat procedure by another physician), 79 (unrelated procedure), and others may apply depending on the circumstances of the service. Consult the CPT manual and payer guidelines for appropriate modifier usage.
Medical necessity is established when there is a clinical indication for RCM to evaluate a skin lesion, scar tissue, or other skin abnormality. The physician must document the need for RCM in the medical record and justify its use in the context of the patient's overall care.
The physician performs the RCM examination, interprets the images, and creates a written report documenting their findings.
In simple words: The doctor uses a special microscope that uses near-infrared light to take detailed pictures of skin tissue. This helps them see any problems within the skin layers. The doctor then looks at the pictures and explains what they found.
This procedure involves using reflectance confocal microscopy (RCM) to acquire images of the cellular and subcellular layers of skin.Near-infrared light is focused on a skin lesion, and the reflected light is captured and displayed by a computer. The provider acquires the image, interprets the results, and generates a report for a single skin lesion. This differs from codes 96932 (image acquisition only), 96933 (interpretation and report only), and 96934 (additional lesions).Do not report this code if the RCM examination does not produce mosaic images; use code 96999 instead.
Example 1: A patient presents with a suspicious mole. The physician uses RCM to image the mole, assesses its characteristics, and determines if further investigation or intervention is needed., A patient has a chronic skin lesion.RCM is employed to evaluate the depth and extent of the lesion, guiding treatment decisions and monitoring progress., A post-surgical patient has suspicious scar tissue formation. The physician uses RCM to assess the tissue composition and determine if any abnormalities are present.
Detailed clinical notes describing the indication for RCM, images acquired during the procedure, the interpretation of the images, and the final diagnostic report.Include patient demographics, date of service, and relevant history.
** Coverage for RCM may vary by payer. It's essential to verify coverage before performing the service.Always utilize the most current CPT codebook for accurate coding.
- Revenue Code: T2D (OTHER TESTS - OTHER)
- RVU: Not available in provided data.Consult the AMA CPT codebook or your payer for RVU information.
- Global Days: Not applicable. This is a diagnostic procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable. This code does not have a technical component.
- Fee Schedule: Not available in provided data. Consult your payer for historical fee schedule information.
- Specialties:Dermatology, Pathology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center