Neurology & Pain Management Coding Alert

But multiple Dx codes can still give you options.

Think you can only report one range-of-motion (ROM) code when your neurologist tests multiple extremities? Think again, because the answer isn't quite so clear cut.

Find out the truth behind using 95831 (Muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk) using these expert tips -- and stop missing out on the reimbursement you deserve.

Manual Muscle Test Means 95831

Abnormalities in the human nervous system can often be detected by assessing muscle strength and tone. When your neurologist manually tests muscles in the arm, leg, or trunk, you should report 95831.

You would use 95831-95852 (Muscle and range of motion testing procedures) if the physician performs a complete range-of-motion or manual muscle testing (for example, to compare the right and left sides).

According to the February 2004 CPT Assistant, you should report 95831-95834 (Muscle testing, manual [separate procedure] with report...) once for each extremity or once for each anatomic body part described within the code descriptor. You should not base the units of service on each muscle tested.

How it works: If your neurologist tested the five muscles in the patient's lower extremity, you would report the testing with 95831 and one unit of service, not five units of service.

Exception: "However, if your provider separately tests multiple muscles in both lower extremities, you would report two units of 95831," says Marvel J. Hammer,RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver, Colo.

Use 95851 for Range of Motion

When your neurologist performs testing of a patient's range of motion of the joints in each arm or leg or sections of the spine in a separately reported procedure, you should report 95851 (Range of motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]). To bill for each extremity or each trunk section measured, such as cervical, thoracic, or lumbar, report  95851 on one line and use the units of service to indicate the number of limbs tested.

Watch out: Some of the procedures or services listed in the CPT manual that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term "separate procedure" in the code descriptor for 95851. You should not report the codes designated as "separate procedure" in addition to the code for the total procedure or service of which it is considered to be an integral component.

CPT designates 95831-95834 as "separate procedures," which means you may report them separately only if your neurologist carries out the procedure independently or considers the procedure to be unrelated or distinct from other procedures/services provided at that time. You may report the separate range of motion or muscle testing along with the other services when it is appropriate, but you'll usually need to append modifier 59 (Distinct procedural service) to the specific "separate procedure" code to indicate that the testing is indeed a distinct independent procedure.

You should expect denials for 95831 and 95851 when you bill those codes at the same time as an E/M visit. The Correct Coding Initiative (CCI) lists both of these codes as the column 2 code to many of the E/M and critical care codes. Unfortunately, you cannot bypass these CCI bundling edits with a modifier.

Bottom line: "Both the manual muscle and range-of-motion testing are considered to be an integral part of the E/M service and not separately reimbursable even if performed at a different session on the same date of service," Hammer says.

Multiple Dx Codes Might Be OK for ROM or Manual Muscle Testing

Many conditions can cause decreased range-of-motion and/or muscle strength loss,so your diagnosis code supporting medical necessity for the testing may depend on your patient's other body systems. For instance, a patient with late effects of a stroke may experience a decreased range of motion and decrease in strength in the affected extremities. You should review the neurologist's documentation to identify what caused the decreased range-of-motion or loss of muscle strength.

Example: Your neurologist's documentation indicates a flexion contracture at the wrist, due to monoplegia of the patient's dominant arm as a late effect of a might look like this:

Right shoulder -- normal ROM: Flexion 180o, Extension 40o, Internal rotation 90o, External rotation 90o,

Adduction 40o, and Abduction 180o Right elbow -- normal ROM: Flexion 160o and Extension 0o

Right wrist -- abnormal ROM: Flexion 45o, Extension -25o, Radial deviation 0o, Ulnar deviation 0o

Muscle strength -- Right Upper Extremity: Deltoid 5+, Biceps 5+, Triceps 5+, Wrist flexors 1-2+,Wrist extensors 1-2+, APB 2+, Intrinsics 2+

For this example, you would report both 718.43 (Contracture of joint, wrist) and 438.31 (Late effects of cerebrovascular disease, monoplegia of upper limb affecting dominant side).

Keep in mind: If you have different primary diagnoses for the different regions or extremities, you may need to separate the services onto individual line items on the claim form and link the corresponding primary diagnosis to each appropriate line. In this case, you will need to append modifier 59 to 95851 on the additional lines so that payers will not mistake these reported services as duplicate billings.

Heads up: To support the claim, the physician's documentation should include a report of the physician's findings for each extremity or spinal section.