Dermatology Coding Alert

Published on Fri Mar 18, 2016 PDF

Question: Is there a code for examination of a hair under a microscope, in cases of alopecia?

New York Subscriber

Answer: CPT^® code 96902 (Microscopic examination of hairs plucked or clipped by the examiner [excluding hair collected by the patient] to determine telogen and anagen counts, or structural hair shaft abnormality) describes this procedure. Alopecia, found in the L63-L66 ICD-10 series, is the most common clinical indicator for this test, also known as a trichogram.

In this procedure, the provider plucks a hair sample from the patient’s head and examines the hairs with a microscope to determine the telogen and anagen counts (i.e., the rest and growth cycle of the hair). He may also use the microscope to detect any structural hair shaft abnormalities. The result of the test reveals the reason for hair loss, which may be hereditary or due to malnutrition and or medication.

Check payer policy: At least one provider, Excellus Blue Cross Blue Shield, has a policy stating, “When microscopic hair analysis is performed during an office visit, the analysis is considered an integral part of the office visit. Therefore, no additional benefits are allowed for the analysis.” Check with your local payers for their policies.