Author: Alysia Delozier, CPC
Professional Coder – Pinnacle Integrated Coding Solutions


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In this procedure, the provider performs manual muscle testing to determine the extent and degree of muscular weakness resulting from disease, injury, or disuse. A formal report must be provided based on grading – see table below.

95831 – Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

95832 – Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

95833 – Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands

95834 – Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands

Abnormalities in the human nervous system can often be detected by assessing muscle strength and tone. When your provider manually tests muscles in the arm, leg, or trunk, you should report 95831.

According to the February 2004 CPT Assistant, you should report 95831-95834 (Muscle testing, manual [separate procedure] with report…) once for each extremity or once for each anatomic body part described within the code descriptor. You should not base the units of service on each muscle tested.

How it works: If your provider tested the five muscles in the patient’s lower extremity, you would report the testing with 95831 and one unit of service, not five units of service.

Muscle testing cannot be coded in addition to an E/M per CCI edits. It is considered bundled with the E/M if done on the same date of service.

General Procedure

Consistency with the testing procedure is critical. For example, changing the point of force application affects the length of the lever arm and therefore the muscle torque – shorter lever arms will provide higher testing scores when compared to using longer lever arms.

Explanation
It is important that the clinician provides instructions to the patient. For example, the following statements may be used:

“I’m going to test the strength of one of the muscles that bends your elbow”

“This is the movement pattern I want you to do. Do it first on your uninvolved side.”

Position Patient
The patient and the part to be tested should be positioned comfortably on a firm surface in the correct testing position. The correct testing position ensures that the muscle fibers to be tested are correctly aligned. The patient is properly draped so that the involved body part is exposed as necessary.

Stabilization
Stabilization, which helps to prevent substitute movements and adds validity to the muscle test, can be provided manually or through the use of an external support such as a belt. The stabilization is applied to the proximal segment using counter pressure to the resistance.

Active Range of Motion
The patient moves through the test movement actively against gravity The clinician palpates the muscle for activity and also notes any adaptive shortening (slight to moderate loss of motion), substitutions or trick movements (weakness or instability), or contractures (marked loss of motion). The joint is then returned to the start position. If the patient is unable to perform the muscle action against gravity, the patient is positioned in the gravity-minimized position. Generally speaking, testing the muscle in the transverse plane can minimize the effects of gravity.

Test
The test should be completed on the uninvolved side first to ascertain normal strength before being repeated on the involved side. The patient is instructed to complete the test movement again and then hold the segment in the desired position. The clinician alerts the patient that resistance will be applied and then applies resistance in the appropriate direction and in a smooth and gradual fashion. The proper location for the application of resistance is as far distal as possible from the axis of movement on the moving segment without crossing another joint. Resistance should never cross an intervening joint unless the integrity of the joint has been assessed as normal. The resistance is applied in a direction opposite the muscle’s rotary component and at right angles to the long axis of the segment (opposite the line of the pull of the muscle fibers). The test is repeated three times and the muscle strength grade is determined. Fatigue with three repetitions may be suggestive of nerve root compression.

Grading

Comparison of MMT grades

Medical Research Council Daniels and Worthingham Kendall and McCreary Explanation
5 Normal(N) 100% Holds test position against maximal resistance
4+ Good + (G+) Holds test position against moderate to strong pressure
4 Good(G) 80% Holds test position against moderate resistance
4- Good – (G-) Holds test position against slight to moderate pressure
3+ Fair + (F+) Holds test position against slight resistance
3 Fair (F) 50% Holds test position against gravity
3- Fair- (F-) Gradual release from test position
2+ Poor + (P+) Moves through partial ROM against gravity OR Moves through complete ROM gravity eliminated and holds against pressure
2 Poor(P) 20% Able to move through full ROM gravity eliminated
2- Poor – (P-) Moves through partial ROM gravity eliminated
1 Trace(T) 5% No visible movement; palpable or observable tendon prominence/flicker contraction
0 0 0% No palpable or observable muscle contraction

In the Medical Research Council scale, the grades of 0, 1, and 2 are tested in the gravity-minimized position (contraction is perpendicular to the gravitational force). All other grades are tested in the anti-gravity position. The Daniels and Worthingham grading system is considered the more functional of the three grading systems outlined in Table 1 because it tests a motion that utilizes all of the agonists and synergists involved in the motion. The Kendall and McCreary approach is designed to test a specific muscle rather than the motion, and requires both selective recruitment of a muscle by the patient and a sound knowledge of anatomy and kinesiology on the part of the clinician to determine the correct alignment of the muscle fibers. Choosing a particular grading system is based on skill level of the clinician while ensuring consistency for each patient, so that coworkers who may be re-examining the patient are using the same testing methods.

It must be remembered that the grades obtained with MMT (Manual Muscle Testing) are largely subjective and depend on a number of factors including the effect of gravity, the manual force used by the clinician, the patient’s age, the extent of the injury, and cognitive and emotional factors of both patient and clinician.

Example 1:

The physician performs manual muscle testing on a patient’s left arm and trunk.

What the coding looks like:

95831 x 2

Example 2:

The physician performs manual muscle testing in three trunk muscles.

What the coding looks like:

95831

Remember: You should base your coding on the number of body parts the physician tests, not the number of muscles the physician tests.

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