Are you being asked to provide a wheelchair assessment? Physicians referring a patient for a wheelchair are required by Medicare, Medicaid other payers to follow guidelines for submitting a prescription and letter of medical necessity. Physicians seek the expertise of physical and occupational therapists in completing the necessary paperwork they must submit in support of the wheelchair request. Therapy providers are often unaware of how to approach the request and unsure how to bill and document the assessment. Is a therapy evaluation necessary as art of wheelchair assessment? How is the wheelchair assessment billed and documented?
Wheelchair Assessment – There’s a Code for That!
CPT® Code 97542 is described as “Wheelchair management (eg, assessment, fitting, training), each 15 minutes” and is used to assess a patient’s need for a wheelchair as well as teaching the patient wheelchair maneuvering skills. This is a time based code, which means that for Medicare it is subject to the 8 minute rule, so for 23 minutes of wheelchair assessment, 2 units of 97542 can be billed, where as for 40 minutes, 3 units can be billed. This code, as an assessment code, can be billed in the absence of a therapy evaluation. However if a therapy evaluation is warranted by the patient’s condition or therapist’s initial assessment, it would be appropriate to bill for the evaluation. Documentation should support the need for both services.
SuperCoder describes the code as
The provider assesses the patient’s functional capabilities and decides on the type and size of wheelchair required. The aim is to select the wheelchair type that provides stabilization, support, and balance as well as pressure management. He teaches the patient wheelchair maneuverability skills and provides instructions for adjustments to the wheelchair and wheelchair use. He also teaches the patient the skills that promote optimal safety, mobility, and transfers to and from the wheelchair.
NGS, the CMS J6 Medicare Administrative Contractor, in LCD L26884 provides guidance to providers in the Jurisdiction when a full therapy evaluation may be indicated:
For many patient situations however, a full patient evaluation is needed to develop the appropriate treatment plan in addition to wheelchair fitting and training. In these situations, it may be appropriate to bill the initial evaluation code (97001 or 97003), with the minutes spent for the evaluation/assessment assigned to either 97001 or 97003. On the day that the evaluation code is billed, the minutes assigned to 97542 should only be related to any wheelchair fitting and training provided, as 97542 is a timed code. For example, if a physical therapist spends 35 minutes gathering the patient history, prior functional status, current functional status, social considerations, range of motion, strength, sensation, balance, and transfers, this time would be assigned to the PT initial evaluation code 97001. As the session continues, the PT spends 45 minutes assessing the patient in a variety of wheelchair set ups, trying a variety of adaptations to best meet the patient’s comfort and functional needs, and initiates training with the patient and family, this 45 minutes would be assigned to code 97542.
Keep in mind that when you are asked to provide a wheelchair assessment in support of a physician’s letter of medical necessity to order the wheelchair that the documentation requires more than filling out the form. Know the payer’s requirements prior to accepting referrals for wheelchair assessments. This will help is determining if wheelchair assessments is a good service at your practice.
Do you do wheelchair assessments? Do you know the payer’s requirements?