Neurology & Pain Management Coding Alert

Question: Our neurology practice recently began performing muscle and range of motion (ROM) testing. Could you tell me more about how to code these services?

Massachusetts Subscriber

Answer: There are separate codes for muscle and ROM testing. First, let’s take a look at the muscle testing codes.

When the notes indicate that your provider performed a manual muscle test, report one of the following codes, depending on encounter specifics

• 95831, Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
• 95832, … hand, with or without comparison with normal side
• 95833, … total evaluation of body, excluding hands
• 95834, … total evaluation of body, including hands

Remember: You should base your coding on the number of body parts the physician tests, not the number of muscles the physician tests.

So if your physician performs manual muscle testing on a patient’s left arm and trunk, you’d report 95831 x 2 for the encounter. If, however, the physician performs manual muscle testing in three trunk muscles, you’d only report a single unit of 95831.

If the notes indicate that the physician performs an ROM test, opt for 95851 (Range of motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]) or 95852 (… hand, with or without comparison with normal side).

Remember the documentation: The descriptors for 99581 and 99582 indicate that you should include measurements and report. According to Evan M. Gwilliam, DC, CPC, CCPC, NCICS, CCCPC, the report should include the following:

• Total encounter time: The ROM codes are “not time-based, but RVUs [relative value units] imply 16-22 minutes,” Gwilliam said during a webinar for the American Academy of Professional Coders (AAPC).
• A written report, identifying specific body areas the physician examined and their grades
• written documentation of medical necessity.