Eli's Rehab Report

Question: If we perform range-of-motion testing on two different extremities, can we report 95851 x 2?

Indiana Subscriber

Answer: Yes, you should report one unit of 95851 (Range-of-motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]) for each arm, leg or spinal section the physician tests manually. To support the claim, the physician's documentation should include a report for each extremity or spinal section that 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, report 95831 (Muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk).
 
For manual muscle testing of the hand with or without comparison with the normal side, use 95832 (... hand, with or without comparison with normal side).  For a total body evaluation, 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 physiatrist may perform them regularly, but 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 service.