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Manual Muscle Tesing with E/M by Neurologist

  1. #1
    Default Manual Muscle Tesing with E/M by Neurologist
    Medical Coding Books
    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.

  2. #2
    Wilmington, NC
    I just read on Encoder Pro that E/M are excluded with code 95834. I ran it thru my CCI editor and it states the codes can not be used together.

    Cynthia Harting, CPC
    Compliance Auditor
    South Eastern Area Health Education Center
    Wilmington, NC

    Wilmington, NC Chapter AAPC
    Marion, OH Chapter AAPC
    Founder/Vice President 2011

  3. #3
    Thanks Cyndi!!! I also ran it through NCCI edits on HCPro's Medicare Find which indicated that a modifier is not allowed to bypass the edit. According to AMA, the 2 codes can be used together if appropriate but NCCI edits do not see it that way! Thanks again!

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