Neurology & Pain Management Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: Can I bill separately for manual muscle testing when it is performed during an office visit?

Alaska Subscriber

Answer: The manual muscle code 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) and 95834 (... total evaluation of body, including hands) are used to identify manual tests of muscle strength that are graded by an examiner according to standard-ized scales and are considered above and beyond any normal muscle testing that a neurologist would perform during an E/M visit as per 1997 HCFA examination guidelines. The definitions emphasize that a report is required for each of the manual muscle testing codes. These codes can be reported separately in addition to an E/M service but please note that the documentation requirements are unclear at present.

Since the AMA has yet to clarify the role of these codes we recommend that you contact your local carrier to discuss what they consider to be appropriate. The American Academy of Neurology says that these codes might be used in a neuromuscular clinic to follow the progression of a patients weakness, for example during a clinical trial, and recommendations on their use are being developed.