Muscle Testing not Payable on Same Date as EM? (California)

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Muscle Testing not Payable on Same Date as EM? (California)

Postby earthwake@aol.com on Thu May 09, 2013 3:41 pm

We have a doctor who bills 95831, 95851, and 95852 testing on the same date as her Initial and P&S visits. They are never paid, apparently because the services were performed on the same day as an EM.

Who comes all the way back to the office just to have a Range of Motion test done? But... I'm wondering if anyone out there has a strategy for getting them paid on the same day as the EM.
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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby occdoc on Thu May 09, 2013 3:55 pm

Yes we have the injuired worker return on another day to complete the computerized measurements and we tell the worker why. Most are not at all surprised. Unless its a QME eval and they they cover it on the same visit. I have a medial director for a bill review company ask me your very questions as why they had to come back. I told him to check with his employer.
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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby jonbrissman on Fri May 10, 2013 6:14 am

The OMFS says that range-of-motion testing (CPT 95851) and grip-strength testing (CPT 95852) are separate procedures, not normally charged on the same date as an E/M code (office visit). The OMFS does not say how an adjuster is to pay for the services when they are billed concurrently. Some adjusters/bill review services pay for the E/M code and disallow the testing, others pay for the testing and disallow the E/M code, and still others pay for whichever is greater. In pursuing recovery for such billing by my clients, I adopt the latter strategy, consistent with Civil Code 3536, "The greater includes the lesser." After all, it doesn't make much sense to think that three ROM charges (at $46.74 each) and a GST (at $34.47) are somehow included in CPT 99211 (for $23.35), for instance. Similarly, my in-house billing service disallows a single ROM charge when CPT 99213, 99214, or 99215 is charged on the same date of service.

In lien trials where the concurrent charges were at issue, WCJs have accepted the approach that the greater of the two charges is payable and the lesser is disallowed. None of those decisions went to the WCAB on reconsideration.

When Sue Honor Vangerov was in charge of the DWC's Medical Unit a few years ago, she said that it was her personal opinion, not speaking for the DWC, that both the testing charges and the office visits should be paid if the testing measurements were included in a report. She said that the OMFS ground rules may be revised to address the issue, but then nothing happened.

Since there is often a dispute when charges for both services are billed concurrently, I advised my clients to bill only for the office visit or for the testing, whichever is greater. Like magic, the disputes disappeared and payment arrived for the service that was billed.

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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby earthwake@aol.com on Fri May 10, 2013 8:55 am

Thank you so much! Really appreciate those thorough responses. You guys are the greatest!
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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby Kashmir on Wed Aug 28, 2013 1:53 pm

Jon, you describe CPT 95852 as grip strength testing, but the code seems to be defined as ROM of the hand. Aren't these two different things?

Also, when billing 95851 for each extremity, is it 2 units for the left and right upper extremities or just 1?

Thanks
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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby jonbrissman on Wed Aug 28, 2013 6:48 pm

CPT 95852 is used both for range-of-motion and grip-strength testing for the hand.

You may bill only one ROM per extremity or trunk, with the exception of both CPT 95851 and 95852 may be billed for an upper extremity. Thus, you may not bill separate ROMS for the left shoulder, left elbow, left arm, etc. -- they are all included in a single ROM charge for the left UE.

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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby Kashmir on Thu Aug 29, 2013 12:22 pm

Thanks for clarifying CPT 95852.

Regarding ROM and 95851, if I understand correctly, you can bill up to four extremities - right upper, left upper, right lower and left lower. And then three for the trunk - cervical, thoracic and lumbar. So hypothetically, if you did ROM for the entire body, you would bill seven 95851 charges, correct? And on top of that two 95852 for each hand?
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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby jonbrissman on Thu Aug 29, 2013 4:00 pm

CPT 95851 for the spine includes both the thoracic and lumbar areas, so there are only two ROMs empowered for the trunk. Reduce the seven CPT 95851 charges to six and everything else you said is correct. However, I cannot recall ever seeing an injury or series of injuries that would justify ROM charges for four extremities plus the trunk plus the cervical spine plus two hands. I suspect that billing for six 95851s and two 95852s would raise a red flag with any adjuster.

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Re: Muscle Testing not Payable on Same Date as EM? (California)

Postby Kashmir on Thu Sep 05, 2013 10:23 am

Thanks again, Jon. Yes, I'm sure red flags would be raising like crazy. I just wanted to make sure I understood the exact breakdown of body parts.
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