2025 CPT code 96932
Effective Date: N/A Medicine - Special Dermatological Procedures Feed
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion.
Modifiers, such as 59 (Distinct Procedural Service), may be applicable in certain situations to indicate that the image acquisition was separate and distinct from other services provided. Refer to current CPT guidelines for specific modifier usage.
Medical necessity for RCM must be established based on the patient's clinical presentation and suspected diagnosis. It is typically used when a more detailed examination of the skin is needed beyond a visual inspection or dermoscopy, often for lesions suspicious for skin cancer.
The clinician's responsibility involves operating the RCM equipment to capture high-quality images of the specified skin lesion at the cellular and subcellular level. This requires precision and technical expertise to ensure that the images accurately reflect the lesion's characteristics and facilitate subsequent interpretation for diagnosis.
In simple words: This procedure involves taking detailed pictures of a skin lesion using a special microscope and a type of light that is invisible to the naked eye. This helps doctors examine the skin closely to see if there are any abnormalities. This specific code is for taking the pictures only.
This code pertains to the acquisition of images for reflectance confocal microscopy (RCM) of a single skin lesion. RCM uses a near-infrared laser to create detailed images of cellular and subcellular structures within the skin, aiding in the diagnosis of various skin conditions. This code covers only the image acquisition process, not the interpretation or report generation, which are billed separately. For additional lesions, other specific codes apply.
Example 1: A patient presents with a suspicious mole. The dermatologist uses RCM to obtain detailed images of the mole's structure (96932) and subsequently interprets those images to determine if it's benign or malignant (96933)., A patient with psoriasis undergoes RCM imaging of a plaque (96932) to assess treatment response. The images are then analyzed (96933) to determine if the treatment is effective., A patient with multiple suspicious lesions has RCM imaging performed on three lesions. The first lesion's image acquisition is coded as 96932. The second and third lesion’s image acquisitions are each coded using 96935. All images are interpreted and reported separately.
Documentation should include patient demographics, lesion location and description, medical history relevant to the skin condition, and the reason for the RCM imaging. The RCM image data itself must also be stored appropriately.
- Specialties:Dermatology, Mohs Surgery, potentially other specialties if trained in RCM techniques.
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center, other settings where RCM equipment is available.