How to Bill for a Wheelchair Evaluation

September 12, 2016
Rick Gawenda

I am often asked how to bill for a patient that is referred to outpatient physical therapy or occupational therapy for the sole purpose of a wheelchair evaluation. I am asked do I just bill the appropriate evaluation code (97001 or 97003)? Do I bill the appropriate evaluation code as well as CPT code 97542 – Wheelchair management (eg, assessment, fitting, training), each 15 minutes? Or do I bill the entire wheelchair evaluation under CPT code 97542? In this article, I will answer how to bill for a patient referred to physical or occupational therapy for the sole purpose of evaluating and assessing for the need of a wheelchair.

In 2006, CPT code 97542 was modified to include the words assessment and fitting in its description. According to CPT Changes 2006: An Insider’s View, “the words assessment and fitting were included in the code descriptor to more completely describe the components of this service”.

Assessment includes, but is not limited to:

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  1. Thanks Rick. I do have a question as it comes up with insurances where we are billing “treatment” with evaluations. Several private insurers do not pay for what they consider treatment prior to the evaluation code being billed (and actually will not pay for treatment on eval day they require a prior auth first). We see many kids strictly for wheelchair evaluations and I agree that this code is very appropriate, however we currently utilize the evaluation codes as when we have billed the WC management code off the bat, it has been denied bases on not billing the eval. Have you heard of this being an issue, or is it something we should attempt to educate our insurers on?

  2. 2 questions: is there a maximum numbers of units that can be billed as 97542? Our wheelchair clinic evaluations can take up to 8 units sometimes. Also, if the patient has Medicare and is being seen for a 1 time wheelchair evaluation, does a POC need to be completed?

    1. Regarding the maximum number of units billed on a given day, you would need to check with the insurance carrier.

      If billing 97542 to Medicare as the first visit, this would require you obtain a signed and dated plan of care from the physician.

  3. If billing only the appropriate number of units of 97542, would we be able to attach G codes since there is no “eval” charge? Or do we even need to???

    1. Since this is the first visit, you would have to select a functional limitation category and report the applicable G-codes.

  4. I’m an OTR currently working in a SNF. Could you please provide me some insight into Med B coverage for WC evaluations and treatment for WC management. Does Med B cover WC vendors who either supply WC accessories for modifying WC or a new WC in general?

  5. Iam an OTR working in a short term SNF setting. My manager is stating that we are to bill 97542 if we need to adjust the height of a wc for a resident. Is this appropriate? Previously, we had a rehab techn that would adjust heights of wc, but now we are told that the therapist has to the adjustment. Please advise.

    1. Under CPT code 97542, fitting of the patient to the wheelchair is included in this code. I am answering this question from an outpatient therapy perspective.