How To Use CPT Code 96934

CPT 96934 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 96934?

CPT 96934 can be used to describe the use of reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of the skin. This procedure involves the provider focusing near-infrared light on the skin to detect any abnormal lesions or scar formation. The light source is connected to a computer that displays the image of the tissue under examination. CPT 96934 is used when the provider saves the images, interprets the results, and reports the findings for each additional skin lesion or area of diseased or damaged tissue.

2. Official Description

The official description of CPT code 96934 is: ‘Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure).’ This code should be used in conjunction with CPT code 96931, which is the primary code for the examination of the first lesion.

3. Procedure

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

4. Qualifying circumstances

CPT 96934 is used when the provider examines each additional skin lesion or area of diseased or damaged tissue using reflectance confocal microscopy (RCM). This procedure is typically performed during the same session as the examination of the first lesion. It is important to note that CPT 96934 should not be reported without an appropriate primary code for the examination of the single lesion (CPT 96931).

5. When to use CPT code 96934

CPT code 96934 should be used when the provider performs reflectance confocal microscopy (RCM) for each additional skin lesion or area of diseased or damaged tissue. This code is used in addition to the primary code (CPT 96931) for the examination of the first lesion. It is important to ensure that the provider captures the images, interprets the results, and reports the findings for each additional lesion or area of tissue.

6. Documentation requirements

To support a claim for CPT 96934, the provider must document the following information:

• Specific details of each additional skin lesion or area of diseased or damaged tissue examined using reflectance confocal microscopy (RCM)
• Date of the procedure
• Start and end time of the procedure
• Images captured during the procedure
• Interpretation of the results
• Report of the findings

7. Billing guidelines

When billing for CPT 96934, it is important to ensure that the procedure is performed in conjunction with the primary code for the examination of the first lesion (CPT 96931). Payers will not reimburse for CPT 96934 if it is reported without an appropriate primary code. Additionally, if the provider only captures the images of the target skin tissue, CPT code 96935 should be used. If the provider only interprets and reports the findings, CPT code 96936 should be used. It is important to follow the specific guidelines provided by the payer and to use the appropriate modifiers if required.

8. Historical information

CPT 96934 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 (RCM) to examine an additional skin lesion on a patient’s arm and provides an interpretation and report of the findings.
2. A plastic surgeon performs reflectance confocal microscopy (RCM) on an area of diseased tissue on a patient’s face and captures images for further analysis and interpretation.
3. An oncologist uses reflectance confocal microscopy (RCM) to examine an additional skin lesion on a patient’s back and provides a detailed report of the findings.
4. A dermatopathologist performs reflectance confocal microscopy (RCM) on an area of damaged tissue on a patient’s leg and interprets the results to aid in diagnosis.
5. A dermatologist uses reflectance confocal microscopy (RCM) to examine an additional skin lesion on a patient’s chest and provides a comprehensive report of the findings.
6. Provide four more examples of cases in which CPT code 96934 should be billed. Only explain the examples and make them all original. Do not include ‘CPT 96934” or ‘CPT code 96934” in the text of an example.