Eli's Rehab Report

Answer: Use 95851 (range of motion measurements and report [separate procedure]) for each extremity (excluding hand) or each trunk section (spine). This code applies to manually testing each arm or leg or sections of the spinal muscles and is a separately reported procedure. To bill for each extremity, the physiatrist should report the procedure on one line of the HCFA 1500 or the claim form, and bill one unit for each extremity. For example, one unit of 95851 would be billed for one extremity, two units for two extremities, and so on. This chart should include a report for each extremity or spinal section examined.

Some physiatrists have reported difficulty getting paid for electronic range-of-motion and electronic muscle testing in various body regions. To report 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, use 95831 (muscle testing, manual [separate procedure] with report; extremity [excluding hand] or trunk). For reporting manual muscle testing for the hand with or without comparison with normal side, use 95832 (... hand, with or without comparison with normal side). For total evaluation of the body, excluding hands, use 95833 (... total evaluation of body, excluding hands). If the total evaluation includes hands, use code 95834 (... total evaluation of body, including hands).

These procedures may be performed regularly and are included in a standard E/M service and so generally will be denied when billed at the same time as an E/M. These codes are normally used when the test is performed independently of the E/M service. Ask the carrier if there are specific reporting requirements for these procedures and obtain this information in writing.