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Range of motion measurements are a critical assessment tool used to evaluate the functional capacity of specific joints, muscles, or muscle groups. This procedure is performed as a separate entity, allowing healthcare providers to focus on the mobility and flexibility of each extremity, excluding the hand, or each section of the trunk, specifically the spine. During the assessment, passive range of motion techniques are employed, wherein the provider actively moves the patient's limb or trunk through the desired range of motion. This method enables the provider to observe and document any limitations in movement, as well as to identify potential weaknesses or instabilities in the joints or muscles being tested. For coding purposes, CPT® Code 95851 is designated for the range of motion testing of each extremity, excluding the hand, or for each section of the spine. It is important to note that for range of motion testing specifically involving the hand, whether compared to the normal side or not, CPT® Code 95852 should be utilized instead.
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Range of motion measurements are indicated for various clinical scenarios where assessment of joint and muscle function is necessary. The following conditions may warrant the use of this procedure:
The procedure for conducting range of motion measurements involves several key steps to ensure accurate assessment and documentation. Each step is crucial for obtaining reliable data regarding the patient's joint and muscle function.
Following the range of motion measurements, the provider may recommend specific follow-up care or interventions based on the findings. Patients may be advised on exercises to improve mobility or strength, and referrals to physical therapy may be considered if significant limitations are identified. It is essential to monitor the patient's progress over time, with repeat assessments scheduled as necessary to evaluate improvements or changes in their condition. Documentation of the procedure and findings should be maintained in the patient's medical record to support ongoing treatment and care planning.
| Short Descr | RANGE OF MOTION MEASUREMENTS | Medium Descr | ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI | Long Descr | Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Service Paid under Fee Schedule or Payment System other than OPPS | Type of Service (TOS) | 5 - Diagnostic Laboratory | Berenson-Eggers TOS (BETOS) | M5D - Specialist - other | MUE | 3 | CCS Clinical Classification | 212 - Diagnostic physical therapy |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GP | Services delivered under an outpatient physical therapy plan of care | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | CQ | Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | GO | Services delivered under an outpatient occupational therapy plan of care | KX | Requirements specified in the medical policy have been met | RT | Right side (used to identify procedures performed on the right side of the body) | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | GA | Waiver of liability statement issued as required by payer policy, individual case | LT | Left side (used to identify procedures performed on the left side of the body) | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | 96 | Habilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. habilitative services also help an individual keep, learn, or improve skills and functioning for daily living. | 97 | Rehabilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CO | Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant | GN | Services delivered under an outpatient speech language pathology plan of care | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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