2025 CPT code 96935

Reflectance confocal microscopy (RCM) for cellular and subcellular imaging of skin; image acquisition only, each additional lesion.

Refer to the Evaluation and Management coding guidelines for further instructions on reporting that is appropriate for management of dermatologic illnesses. (For intralesional injections, see 11900, 11901) (For Tzanck smear, see 88160-88161)

Modifiers may be applicable, such as 59 (Distinct Procedural Service) or 76 (Repeat Procedure or Service by Same Physician) if appropriate.

Medical necessity should be established by documenting the patient's signs, symptoms, or history that warrant the use of RCM to examine additional lesions.

The provider examines the cellular and subcellular layers of the skin with an imaging device to detect abnormalities.The microscope focuses near-infrared light through a laser diode onto the skin, and the reflected light is captured by a computer to create images.

IMPORTANT (Use 96935 in conjunction with 96932)

In simple words: This procedure uses a special microscope and light to create images of your skin to look for any abnormalities.This code is used for each additional skin area examined after the first one.

This procedure uses near-infrared light focused on the skin to detect abnormal lesions or scar formation. The light source connects to a computer that displays the image of the tissue under examination. This code is used for the imaging procedure for each additional skin lesion, area of diseased or damaged tissue examined during the same session.

Example 1: A patient presents with multiple suspicious moles.96932 is reported for the examination and imaging of the first mole, and 96935 is reported for each additional mole imaged during the same session., A patient with a history of skin cancer has several areas of concern identified during a skin check.96932 is used for the first lesion, and 96935 is used for each subsequent lesion imaged., A patient has a rash with multiple distinct areas of involvement.The physician uses RCM to examine several of these areas during the same encounter. 96932 is reported for the first area examined, and 96935 is reported for each additional area.

Documentation should include the number and location of lesions examined, the medical necessity for the procedure, and the interpretation of the images obtained.

  • Revenue Code: P6A - MINOR PROCEDURES - SKIN
  • Specialties:Dermatology
  • Place of Service:Office, Outpatient Hospital
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