Eli's Rehab Report

Question: In my fiscal intermediary’s local coverage determination (Cahaba GBA for Alabama), under 97542 (Wheelchair management [e.g. assessment, fitting, training], each 15 minutes), it says not to bill an OT evaluation (97003) if the visit’s sole purpose is for a wheelchair assessment. First, what is the real difference between an evaluation and assessment? Also, wouldn’t the patient have needed an evaluation (97001 or 97003) for his plan of care at one point? If so, would we be penalized for billing 97542 alone?

Answer: To answer your first question, an evaluation is more comprehensive and global, whereas an assessment, such as for a wheelchair using CPT® code 97542, is more specific to a particular area or need that the patient has. The same would be true for CPT® codes 97755 (assistive technology assessment) and 97760 (orthotic assessment).

As for your second question, a patient may come in for a wheelchair assessment only (without being on a rehab plan of care). Your Medicare contractor, at first glance, may consider 97542 without an evaluation code, to be incorrect, but you can fight this in an appeal.

For example, National Government Services (NGS) PT and OT LCD for Ohio states, “there may be circumstances where a patient may be seen one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only an assessment related to specific wheelchair needs, this one-time only session may be billed under 97542 with the appropriate units reflecting the time spent in the assessment.”

Keep in mind: Some situations may call for both 97001/97003 and 97542. For instance, consider a patient who needs a more comprehensive therapy evaluation and plan of care that happens to include wheelchair training at some point. What you cited in your LCD was stressing situations where a wheelchair assessment is the sole purpose of the visit.

The NGS PT and OT LCD spells out billing details in an example: If a 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 patients comfort and functional needs, and initiates training with the patient and family, these 45 minutes would be assigned to code 97542.