How To Use CPT Code 96931

CPT 96931 describes the use of reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of the skin. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 96931?

CPT 96931 can be used to describe the use of reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of the skin. This code is used when the provider focuses near-infrared light on the skin to detect any abnormal lesions or scar formation. The light source connects to a computer that displays the image of the tissue under examination. The provider saves the image, interprets the result, and reports the findings for a single skin lesion or area of damaged or diseased tissue.

2. Official Description

The official description of CPT code 96931 is: ‘Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion.’ It is important to note that this code should only be used when the provider generates mosaic images related to a single lesion. If the procedure does not produce mosaic images, CPT code 96999 should be used instead.

3. Procedure

1. The provider examines the cellular and subcellular layers of the skin using an imaging device.
2. They focus near-infrared light through a laser diode on the target skin, which reflects the light back in different proportions.
3. The diode connects to a computer that captures and displays the images of the skin tissue under examination.
4. The provider saves the images, interprets them, and reports the findings for a single skin lesion or area of damaged or diseased tissue.

4. Qualifying circumstances

CPT 96931 is used for the imaging of skin lesions or areas of damaged or diseased tissue. It is important to note that this code should only be reported when the provider generates mosaic images related to a single lesion. If the procedure does not produce mosaic images, CPT code 96999 should be used instead.

5. When to use CPT code 96931

CPT code 96931 should be used when the provider performs reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of the skin, and generates mosaic images related to a single lesion. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code.

6. Documentation requirements

To support a claim for CPT 96931, the provider must document the following information:

• Description of the skin lesion or area of damaged or diseased tissue
• Images captured during the procedure
• Interpretation of the images and findings
• Report of the results

7. Billing guidelines

When billing for CPT 96931, ensure that the procedure meets the specific criteria outlined in the official description of the code. It is important to note that this code should only be used when the provider generates mosaic images related to a single lesion. If the procedure does not produce mosaic images, CPT code 96999 should be used instead. It is also important to check with the Medicare provider or private carrier to determine their coverage policies for reflectance confocal microscopy.

8. Historical information

CPT 96931 was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A dermatologist uses reflectance confocal microscopy to examine a suspicious mole on a patient’s skin and generates mosaic images for interpretation and reporting.
2. A plastic surgeon performs reflectance confocal microscopy on a scar tissue to assess its cellular and sub-cellular characteristics and generates mosaic images for interpretation and reporting.
3. An oncologist uses reflectance confocal microscopy to examine a skin lesion in a cancer patient and generates mosaic images for interpretation and reporting.
4. A dermatopathologist performs reflectance confocal microscopy on a skin biopsy sample to analyze the cellular and sub-cellular structures and generates mosaic images for interpretation and reporting.
5. A dermatologist uses reflectance confocal microscopy to assess the vasculature of the skin in a patient with a suspected vascular disorder and generates mosaic images for interpretation and reporting.
6. A plastic surgeon performs reflectance confocal microscopy on a patient’s skin to evaluate the effectiveness of a cosmetic procedure and generates mosaic images for interpretation and reporting.
7. An oncologist uses reflectance confocal microscopy to examine the margins of a skin tumor during surgery and generates mosaic images for interpretation and reporting.
8. A dermatopathologist performs reflectance confocal microscopy on a skin lesion to differentiate between benign and malignant cells and generates mosaic images for interpretation and reporting.
9. A dermatologist uses reflectance confocal microscopy to monitor the progression of a skin condition in a patient and generates mosaic images for interpretation and reporting.
10. An oncologist performs reflectance confocal microscopy on a skin metastasis to assess the cellular and sub-cellular characteristics and generates mosaic images for interpretation and reporting.