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2025 CPT code 95851

Measures range of motion in each extremity (excluding hand) or spinal section; report includes measurements and findings.

Follow standard CPT coding guidelines for neurology and musculoskeletal procedures.One unit of 95851 is reported per extremity (excluding the hand) or spinal section.

Modifiers may apply depending on the circumstances.Consult the CPT manual for modifier use. Examples include modifier 52 (reduced services) if the exam is incomplete or modifier 76 (repeat procedure) if repeated.

The medical necessity for ROM measurements is typically established by the presence of musculoskeletal symptoms (pain, stiffness, weakness), suspected neurological deficits, or the need to assess functional limitations following injury or surgery.The physician must document the clinical indication for the procedure.

The physician or qualified healthcare professional is responsible for performing the range of motion measurements, interpreting the results, and generating a formal report.

IMPORTANT:No alternate codes explicitly noted.However, depending on the context and the comprehensive examination performed, other related CPT codes for musculoskeletal evaluations or neurologic examinations might be appropriate.

In simple words: The doctor measures how much you can bend and straighten your arm, leg, or back. They use a special tool to measure the angles of movement. This is usually done as part of a bigger exam.

This CPT code encompasses the manual measurement of range of motion (ROM) in a single extremity (excluding the hand) or a single spinal section.The provider uses a goniometer to measure the degrees of movement from full extension to full flexion. Both active (patient-initiated) and passive (provider-assisted) ROM may be assessed.A formal report documenting the findings is generated.One unit is reported for each extremity or spinal section examined.This procedure is often a component of a larger procedure, in which case the service is included in the main procedure code.

Example 1: A patient presents with neck pain following a motor vehicle accident. The physician performs ROM measurements of the cervical spine to assess the extent of injury and guide treatment., A patient with suspected carpal tunnel syndrome undergoes ROM measurements of the wrist and hand to evaluate functional limitations and assess the severity of the condition.(Note: This would require additional coding for the carpal tunnel evaluation itself, as 95851 excludes the hand.), During a routine physical examination, a senior patient demonstrates limited ROM in the knee.The physician documents the ROM assessment as part of a comprehensive evaluation.

* Detailed documentation of the specific joint(s) or spinal section(s) examined.* The method used to measure ROM (e.g., goniometer).* Numerical measurements in degrees for both active and passive ROM (if assessed).* A clear description of the patient’s movement and any limitations encountered.* Clinical indication for performing the ROM assessment.* Formal report summarizing findings and their implications.

** The exclusion of the hand from this code necessitates careful documentation to justify the medical necessity for the specific body parts assessed.Always consult current CPT and payer guidelines for proper coding practices.

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