by Wyn Staheli, Director of Content - innoviHealth
Nov 8th, 2018
Muscle and Range of Motion testing testing require an understanding of their unique components to ensure proper usage and avoid billing problems. It should be noted that neither is a time based code and both are designated as a "separate procedure" and therefore should be paid when there is evidence that there is a need for this service to be separated from another service (e.g., Evaluation and Management service). However, It should be noted that some payers will simply not pay for these services -- period.
- It is critical for the documentation to explain WHY the service is not 'routine'.
- Do NOT perform these services on the same day as a physical (97161-97163) or occupational (97165-97167) therapy evaluation.
- CMS has stated that it is not reasonable or necessary for these services to be performed on a routine basis or to be routinely used for all patients.
- It is appropriate and necessary to add modifier 59 to these codes when performed on the same day as an E/M visit or other similar patient encounter (e.g., Chiropractic Manipulative Treatment).
- From a patient perspective, when these needed tests are not routine, they should be done on the same day as the E/M service.
- In rare circumstances, it may be necessary to add modifier 22 when there are unusual circumstances that increase the procedure.
Official CPT guidelines for separate procedures states the following (emphasis added):
The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
However, when a procedure or service that is designated as a ‘separate procedure’ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure is not considered to be a component of another procedure.
A comparison of the Relative Value Units (RVUs) reveals that 37% (for muscle) and 20% (for range of motion) of the total RVU is associated with the Physician Work component in these codes. This confirms the fact that these are brief tests which could be associated with routine E/M physical examinations.
Manual Muscle Testing (MMT)
MMT (95831-95834) is used to determine the patient's ability to voluntarily contract specific muscle(s). The patient is asked to hold a specific position or move (e.g., flexion, extension, abduction, or adduction) while the healthcare provider applies resistance (i.e., gravity, manual force). The provider must stabilize the proximal part of the area being tested to reduce muscle compensatory action not in the area being tested. It is recommended that these tests be used in accordance with functional tests (e.g., 97750) to coordinate these deficits with functional goals.
MMT is clinically indicated when there is suspected or actual impaired muscle performance (e.g., impaired strength, power, or endurance). It is contraindicated for recent fractures, post-surgical conditions, tissue healing issues, or cognitive deficits. The patient must be able to participate and sustain the required testing postures or movements.
The following information from AMA's CPT Assistant, August 2013 provides guidance: “Given the subjective aspect of manual testing, the use of consistent test positions, including accurate joint placement and avoiding the use of compensatory muscle actions, must be integrated into the test in order for MMT to be utilized as an effective evaluation tool.”
CLICK HERE to review a manual muscle testing tables with the necessary grades.
CLICK HERE to review the AMA's August 2013 CPT Assistant article.
Range of Motion Testing (ROM)
ROM testing (95851-95852), according to the AMA's August 2013, CPT Assistant, "refers to the angular distance in degrees through which the spine or a joint can be moved. ROM testing is typically performed to assess the amount and quality of movement in multiple planes of motion including the assessment of the capsular end feel of the joint, observation of muscle substitution patterns due to weakness of specific muscles, and documentation of pain, tonus, and crepitus at specific places in the arc of motion. This type of testing is not time based and is differentiated from strength testing.
These tests are increasingly being denied when billed with Evaluation and Management services with a quote from the 1997 Documentation Guidelines for Evaluation & Management Services which states that the exam includes an “Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture.” However, the problem is that this is a visual assessment. True ROM testing with codes 95851-95852 requires actual measurements and a separate written report. Additionally, the results of the ROM need to be included as part of the treatment plan goals to support medical necessity.
CLICK HERE for a comprehensive article about when it is appropriate to use these codes and ways to deal with the problem of claim denials.
CLICK HERE to review the CDC's Normal Joint Range of Motion Tables.
CLICK HERE to read an article by an auditor arguing against using these codes with an E/M or Chiropractic Manipulative Treatment.
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.