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Old 04-07-2011, 03:02 PM
Brenda Ray Brenda Ray is offline
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Default Manual Muscle Testing with E/M by Neurologist

Neurologist is seeing a patient for followup of radiculopathy and neuropathy. She performs a neurological exam including cranial nerve exam, motor exam, sensory exam, coordination, and gait exams.

Under motor exam, she has a table/grid containing numerical values for each muscle strength tested. Is this information enough to assign CPT 95834? Not sure if this grid of numerical values per muscle constitutes a 'formal written report of the findings' that CPT Assistant references must be present in order to code this. (CPT Assistant, December 2003 Page: 7 and , November 2001 Pages: 4, 5). Otherwise, this manual muscle testing is included in the Physical Examination component of the E/M. Neurologist has coded E/M 99213 only but was wondering if the motor exam could be coded separately with documentation of the grid values per muscle.
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