2025 CPT code 96933
Effective Date: N/A Medicine - Special Dermatological Procedures Feed
Reflectance confocal microscopy (RCM) for cellular and subcellular imaging of skin; interpretation and report only, first lesion.
Modifiers may be applicable. Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity for RCM should be supported by documentation of a suspicious skin lesion where standard dermoscopy is inconclusive, or for monitoring treatment response in specific skin conditions.
The physician examines the cellular and subcellular layers of the skin with an imaging device to detect abnormalities in the vasculature and microstructure. The physician uses a special microscope to examine a single lesion on the skin by focusing near-infrared light on the target area, and the reflected light is processed to create images. The physician interprets the images and reports the findings.
In simple words: This procedure uses a special microscope and a computer to create detailed images of your skin. A near-infrared light is shined onto your skin, and the way it reflects back creates a picture of the cells in your skin. This helps the doctor check for any abnormalities, like skin cancer or other skin conditions, without needing a biopsy.This code covers the doctor's work of looking at and explaining the images for one skin area.
Reflectance confocal microscopy (RCM) is a non-invasive imaging technique that uses near-infrared light to visualize cellular and subcellular structures within the skin. This code is specifically for the interpretation and report of the findings for the first skin lesion examined using RCM. The procedure involves focusing a near-infrared laser on the skin, which reflects light back to a detector. The reflected light is then processed to create detailed images of the skin's microstructure. This allows for in vivo visualization of the epidermis and papillary dermis, aiding in the diagnosis of skin conditions.
Example 1: A patient presents with a suspicious mole. Dermoscopy is inconclusive. RCM is performed, and the images reveal features consistent with melanoma, prompting a biopsy., A patient with psoriasis undergoes RCM to assess the effectiveness of treatment. The images show improvement in skin structure and reduction in inflammation., A patient with a history of basal cell carcinoma has a new lesion. RCM is used to evaluate the lesion, and the images suggest a recurrence, leading to further treatment.
Documentation should include clinical findings, dermoscopic findings (if performed), reason for RCM, location and description of the lesion, interpretation of the RCM images, and any associated diagnosis or treatment plan.
** Code 96931 is used for image acquisition and interpretation of the first lesion, while code 96932 is for image acquisition only. Code 96935 is used for the interpretation and report of each additional lesion.RCM is useful for evaluating melanocytic lesions, non-melanoma skin cancers, inflammatory skin diseases, and assessing surgical margins.
- Revenue Code: T2D
- Specialties:Dermatology, Mohs Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center