Neurology & Pain Management Coding Alert

Question: Should I report 95851 once per extremity or once per session, regardless of the number of limbs the neurologist tests?

Arizona Subscriber Answer: You should report 95851 (Range-of-motion measurements and report [separate procedure]; each extremity [excluding hand] or each trunk section [spine]) per limb that the neurologist tests.
 
Code 95851 describes manual testing of each arm or leg or sections of the spinal muscles in a separately reported procedure. To bill for each extremity, report 95851 on one line of the CMS-1500 or claim form and multiply it by the number of limbs tested. For example, if the neurologist tests both arms, you should use 95851 x 2. Documentation should include a report for each extremity or spinal section the neurologist examines.
 
CPT includes several "range-of-motion" codes other than 95851.
  To document manual range-of-motion measurements for the hand, with or without comparison with normal side, use 95852 (Range-of-motion measurements and report [separate procedure]; hand, with or without comparison with normal side).
  To report manual muscle testing for the arm, leg or trunk, you should claim 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 normal side, report 95832 (Muscle testing, manual [separate procedure] with report; hand, with or without comparison with normal side).
  For total evaluation of the body, excluding hands, the correct code is 95833 (Muscle testing, manual [separate procedure] with report; total evaluation of body, excluding hands).
  If the total evaluation includes hands, select 95834 (Muscle testing, manual [separate procedure] with report; total evaluation of body, including hands). Payers will regularly bundle any of the above services into any E/M service that the neurologist provides on the same day. Therefore, you can expect denials for 95851-95852 and/or 95831-95834 when you bill them at the same time as an E/M visit. You may only report the range-of-motion testing separately if the neurologist provides the service independent of an E/M service.