CATEGORY
physical medicine and rehabilitation therapeutic procedures
CODE TYPE
Timed-based code
ADD-ON CODE
No add-on code
WHEELCHAIR MANAGEMENT
- Assessment to evaluate the patient’s need for a wheelchair .
- Measurements before ordering the equipment such as ROM, sitting balance, muscle strength, sensations, and ability to transfer in and out of the chair .
- Instructions on adjustments to the wheelchair for optimal use .
- Training for proper wheelchair skills such as propulsion, maneuverability skills, and safety techniques as well as training to navigate in all types of situations and environments such as home, facility, work, and community .
- Training about proper positioning to avoid pressure points, contractures, and other medical complications .
- Wheelchair Management is done in patients who can learn to navigate the wheelchair
independently. - 3 to 4 sessions are usually required for assessment, fitting, and training for a wheelchair .
CODING GUIDELINES
» Require the skills of qualified healthcare professionals that includes:
- Physical Therapist
- Occupational Therapist
- Chiropractors
- Physical Therapist Assistant
- Occupational Therapy Assistant
» Billed in 15 minutes increment
» Requires physical therapy modifier (GP, GN, GO, CO, CQ)
» CMS 8-minute rule and AMA rule of Eights are applied
CMS 8-Minute Rule:
A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97542 to be billed:
| Units | Number of Minutes |
|---|---|
| 1 unit | ≥ 08 minutes through 22 minutes |
| 2 units | ≥ 23 minutes through 37 minutes |
| 3 units | ≥ 38 minutes through 52 minutes |
| 4 units | ≥ 53 minutes through 67 minutes |
| 5 units | ≥ 68 minutes through 82 minutes |
| 6 units | ≥ 83 minutes through 97 minutes |
| 7 units | ≥ 98 minutes through 112 minutes |
| 8 units | ≥ 113 minutes through 127 minutes |
The pattern remains the same for treatment times of more than 2 hours.
AMA Rule of Eights:
“AMA guidelines state that incremental intervals of treatment performed on the same session may be added together when determining total time in direct contact of a qualified healthcare provider with the patient is necessary. Each unique timed service is counted separately instead of combining the time from multiple units”
COMMON TREATMENT DIAGNOSIS
- Abnormality of gait
- Abnormal posture
- Difficulty walking
- Weakness
- Lack of coordination
PHYSICAL THERAPY MODIFIERS
Below mentioned modifiers are used when services are provided for the respective plan of care:
| MODIFIERS | PLAN OF CARE |
|---|---|
| GP | Outpatient Physical Therapy |
| GO | Outpatient Occupational Therapy |
| GN | Outpatient Speech-Language Pathology |
| CQ | Outpatient Physical Therapy by a Physical Therapist Assistant (completely or partially) |
| CO | Outpatient Occupational Therapy by an Occupational Therapy Assistant (completely or partially) |
TOTAL NO. OF BILLABLE UNITS
08 units are allowed per date of service by CMS but more units can be billed if justified by medical notes.
REIMBURSEMENT GUIDELINES
For reimbursement of these CPTs following elements must be documented in the Physical Therapy Notes:
- Documentation of medical condition to justify the medical necessity of skilled intervention by the therapist.
- Documentation of the patient’s need for a wheelchair whether they will need a powered or manual wheelchair.
- Documentation of the skilled services rendered by the Physical Therapist .
- Documentation of the functional goals that are achievable by the patient .
- Total direct time spent by the provider with the patient as well as the total duration of the treatment session .
- To meet coverage criteria, therapy services have these requirements in common:
- Documentation of improvement from therapy using objective assessment tools and measurements and functional accomplishments .
- The therapy plan is developed by a qualified/certified healthcare professional .
INSURANCES COVERAGE CRITERIA
- For Medicare insurance, the multiple procedure payment reduction (MPPR) policy applies to this CPT.
- Under MPPR, when multiple “Always Therapy” services are provided to the same patient on a single date of service even if the services are provided in a separate session, the procedure with the highest practice expense value that day is reimbursed at 100 percent, and all other subsequent services are paid at 50 percent.
- For commercial Insurance, the amount of reduction may vary according to the insurance plan.
- Part of an active treatment plan tailored to the specific needs of the patient.
