Neurology & Pain Management Coding Alert

Question:  The PM specialist performs manual muscle testing on three muscles in a patient’s left trunk and a single muscle in the patient’s left hand. How should I report this encounter?

Nebraska Subscriber

Answer: You should be able to report a pair of codes for this service. On the claim, report:

• 95831 (Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk) for the trunk muscle test
• Modifier LT (Left side) appended to 95831 to indicate laterality, if the payer requires it
• 95832 (... hand, with or without comparison with normal side) for the hand muscle test 
• Modifier LT appended to 95832 to indicate laterality, if the payer requires it.

Remember: It doesn’t matter how many muscles the provider tests during the service; it’s the number of overall body parts the provider tests.