2025 CPT code 96936
(Active) Effective Date: N/A Medicine - Special Dermatological Procedures Feed
Reflectance confocal microscopy (RCM) for cellular and subcellular imaging of skin; interpretation and report only, each additional lesion.
While modifiers are generally allowed on codes, the use of modifiers with 96936 is rare and specific. Consult official coding guidelines before applying any modifiers to 96936.
Medical necessity for 96936 must be supported by the presence of additional suspicious skin lesions beyond the initial lesion evaluated with 96933.Documentation must justify the need for RCM on each additional lesion, relating it to the patient's presenting symptoms, medical history, and suspected diagnosis.The medical record should demonstrate that each additional lesion examined required separate interpretation and reporting, beyond the work involved in examining the primary lesion.
The physician examines the cellular and subcellular layers of the skin using reflectance confocal microscopy (RCM) to detect abnormalities. The physician interprets the images produced by the RCM and creates a report of the findings for each additional lesion examined during the same session as the primary lesion.
In simple words: This code covers the doctor's analysis and report of additional skin images taken with a special microscope that uses light to look at the skin in detail. This is done alongside the initial skin check (code 96933). The microscope uses a type of light that can see things beneath the surface of your skin.
This code is used for the interpretation and report of reflectance confocal microscopy (RCM) for each additional skin lesion, in addition to the primary procedure (96933). RCM uses near-infrared light to examine cellular and subcellular layers of the skin for abnormalities.The light is focused on the skin, reflects back, and the reflected light is then interpreted by a computer to create an image.This code is for the physician's interpretation of those images, not the image capturing itself.
Example 1: A patient presents with multiple suspicious moles. The physician performs RCM on the first mole (96933) and then performs RCM on two additional moles (96936) during the same encounter. The physician interprets the images and reports the findings for each lesion., A patient with a history of skin cancer has several areas of concern on their back. The dermatologist uses RCM to examine the first area (96933) and then examines three additional areas (96936 x 3) during the same visit to monitor for recurrence. They interpret the images and document their findings for each area examined., A patient has a rash with several distinct lesions. The physician performs RCM on the largest lesion (96933) and then two smaller lesions (96936) to determine the nature of the rash and guide treatment. They interpret the RCM images from each lesion and report the findings.
Documentation should include the number and location of lesions examined by RCM, the medical necessity for examining each lesion, the interpretation of the RCM images for each lesion, and a report of the findings.