CPTs Â® 95831-95834 and 95851-95852
Muscle strength and range of motion (ROM) testing involves additional skilled medically reasonable and necessary assessment of the patient by a qualified clinician. When these services are provided on the day of the initial evaluation or re-evaluation, then the testing is considered to be inclusive in the same day evaluative service (which is appropriately billed using either CPT Â® 97001 or 97002). However, it is reasonable to assume that the therapist may determine that the patient requires additional testing services that may also be separately reimbursable. For example, when strength and/or ROM assessment services are NOT provided on the same day as an initial evaluation or re-evaluation, then they may be appropriately billed using 95831-95834 or 95851-95852. In all circumstances, the medical record documentation must clearly identify and support the timing rationale for the provision of these additional assessment services. Note that routine assessments for the purpose of documenting the patientâ€™s expected progression in accordance with the plan of care are not considered to be separately reimbursable services. Documentation to support the use of these CPT codes must include a formal, distinctly identifiable, date signed written report of the findings. Each report must include testing of muscle strength and/or range of joint motion with comparison of values to a specific standardized grading scales. The written report must include the providerâ€™s interpretation of the results. When applicable, documentation shall support how these findings are incorporated into the therapy plan of care. Muscle testing and/or range of motion measurements that are performed: a) without recording specific values for the muscles tested or range of joint motion measured or; b) without the completion of a distinct separate report, should not be reported with codes 97831-95834 or 95851-95852. Note that these are untimed codes and it is not appropriate to bill for more than 1 unit per treatment session.
References: MBPM, Chapter 15, Section 230.1(C); MBPM, Chapter 16, Section 150; and the CPT Â® Coding Guidebook
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