Neurology & Pain Management Coding Alert

Question: May I report 95851 x 2 for testing two different extremities?

Indiana Subscriber

Answer: Yes, you should report one unit of 95851 (Range of motion measurements and report [separate procedure]; for each extremity [excluding hand] or each trunk section [spine]) for each arm, leg or spinal section the physician tests manually. For example, for one leg and on arm, report 95851 x 2. To support the claim, the physician's documentation should include a report for each extremity or spinal section the physician examines.
 
Other codes in this series follow similar guidelines. To report manual range-of-motion measurements for the hand, with or without comparison with the normal side, use 95852 (Range of motion measurements and report [separate procedure]; hand, with or without comparison with normal side). For manual muscle testing of the arm, leg or trunk, use 95831 (Muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk).
 
For manual muscle testing for the hand with or without comparison with the normal side, use 95832 (... hand, with or without comparison with normal side).
 
For total evaluation of the body, excluding hands, report 95833 (... total evaluation of body, excluding hands). If the total evaluation includes hands, use 95834 (... total evaluation of body, including hands).
 
CPT designates 95831-95834 as "separate procedures." A neurologist may perform them regularly, and payers will bundle them to any standard E/M service. Payers will not pay separately for range-of-motion measurements performed at the same time as an E/M.