MS requires a licensed/certified medical practitioner (LCMP—such as an occupational or physical therapist) to be involved in assessments for certain mobility assistive equipment (MAE)—specifically, certain powered mobility devices. There have been concerns from clinicians and providers as to how LCMPs can charge for these services, and whether the reimbursements are adequate to make these types of services worthwhile.

It is true that at one time, wheelchair assessments and services were not an attractive area of practice for OTs and PTs given the amount of work, time, and documentation required. Many wheelchair clinics shut down over the years because they required a great demand of resources with limited reimbursements. While the reimbursement situation has changed a bit in the past 2 years, many therapists still perceive wheelchair assessments as a money losing proposition.

Therapists can be reimbursed by Medicare and other payors for MAE assessments and services under recent changes to the updated Common Procedural Terminology (CPT) coding system. A clinician's ability to bill for these services may vary by region depending on local coverage determinations (LCDs), managed care policies, other services (such as hospice or home health care), and the setting in which the client resides. Therefore, it is important for clinicians and suppliers to be aware of specific policies in their region.

Share the information in this article with potential therapy referral sources to make them aware of new opportunities to expand their practices into new areas. There is a shortage of therapists with specific knowledge in the area of wheeled mobility and seating, and there is also a shortage of therapists with assistive technology practitioner (ATP) certifications. Nonetheless, it is time for therapists and providers to again start working more closely together.

Mark R. Schmeler

Qualified suppliers (ATSs and certified rehabilitation technology suppliers [CRTSs]) bring much knowledge related to the different technologies and their applications. However, therapists are specifically trained to perform assessments and determine functional deficits that cannot be addressed through traditional therapies and therefore require MAE. The two, working with the client and under the referral of a physician, can make for a good team—and we should have been working together consistently all along. After all, CMS is promoting this cooperation in the new policies.

Physicians and therapists also need to remain financially removed from the suppliers of the equipment, which is consistent with most other areas of health care. Imagine how vulnerable one might feel being treated and prescribed a medication by a physician who owns the pharmacy or has significant shares in a pharmaceutical company. It leaves you to wonder whether this is the best treatment or just a financial interest.

OTs and PTs can typically bill Medicare and other payors for their services with financial separation as independent practitioners, and their practices are governed by state licensure laws (practice acts) and national certifying bodies that mandate standards of practice and codes of ethics.

MAE ASSESSMENTS AND SERVICES

First, a PT or OT must perform a traditional therapy assessment (CPT code 97001 for PTs and 97003 for OTs). This is a "non-timed" procedure—meaning no matter how much time the therapist spends with the client on documenting, reimbursement is the same. The allowable is based on a traditional therapy assessment that usually takes about a half to three quarters of an hour with standardized documentation procedures. Traditionally, this did not work well financially for wheelchair assessments, especially complex cases, and did not consider the amount of "behind the scenes" legwork and documentation. The assessment procedure is still required to initiate and identify the need for an MAE device. However, other CPT codes are available after the assessment procedure that can be used for clinical billing.

A few years ago, thanks to the efforts of some key practitioners and national associations, including the American Occupational Therapy Association (AOTA) and the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA), a new CPT code was approved for "assistive technology assessment" (97755). This code allows clinicians to focus more on the restoration, augmentation, and compensation of functional tasks through the use of AT interventions. It also recognizes environmental accessibility as a factor in a person's ability to perform functional activities.

The 97755 code is a per-unit (15 minute) "timed" code that factors documentation into the equation. Therefore, clinicians have more flexibility in how much time they feel is necessary to spend with their client. The problem with the 97755 code is that it cannot be billed on the same day as the 97001 or 97003 codes, which creates significant burdens for clients, caregivers, and therapists. CMS has also recognized this code as being appropriate only for people who require complex multisystem AT interventions such as a power wheelchair with alternative controls—in combination with perhaps a communication device or adaptive computer access.

An alternative to 97755 is the wheelchair management code (97542). In the past, this code was limited in definition with a low allowable. However, the definition and allowable were updated for 2006 to further expand on what is really involved in the assessment and provision of wheeled mobility and seating interventions. This code (like 97755) is a timed per unit code, and takes into account documentation. In most cases, it can be billed on the same day as 97001 or 97003 using a modifier (check with your local fiscal intermediary). It is also more specific to "all" wheelchairs, not just complex AT as with 97755.

The language of 97542 also reflects a best practice in the provision of wheeled mobility in that the clinician needs to consider variables such as the need for wheeled mobility in the context of the client's strength, tone, sitting balance, endurance, ability to perform activities of daily living, living situation, environmental accessibility, transportation, work, transfers, weight, body dimensions, skin integrity, and ability to weight shift.

The wheelchair management code can be used not only for the assessment portion of the process, but also for training at the point of delivery. This process might include the client's ability to maneuver, propel, make adjustments, and solve problems in real-life situations.

A REAL-WORLD SITUATION

Assume that a person with C4-5 tetraplegia is referred for a mobility assessment. The therapist spends 30 to 45 minutes performing an intake interview, followed by physical examination, and determines the person is in need of a more complex power wheelchair—as well as adaptive computer access. It would be appropriate to bill the 97001 or 97003 evaluation code and document the assessment findings—followed by a treatment plan that would include subsequent visits when more in-depth assessments could be performed. Additional elements of the treatment plan would include trial equipment using the 97755 code based on however much time is reasonably needed to meet the treatment goals.

As a contrast, imagine an older person with multiple joint arthritis, congestive heart failure, diabetic neuropathy, and obesity that is referred to a therapist for a mobility assessment. The therapist performs a traditional therapy assessment and determines a power wheelchair is indicated. The therapist can bill the 97001 or 97003 assessment code, followed by the appropriate amount of units for 97542 as different types of power wheelchairs are available to test on the same day. Pending a home assessment (if the assessment is performed in a clinic), both codes can be billed on the same day. The wheelchair management code can also be used when the wheelchair is delivered in the presence of the therapist, and the person is trained in proper use.

Additional issues for therapists include therapy caps and home health care episodes that might affect their ability to bill for services. For this reason, it is again important to know and verify local coverage issues. But for the most part, payors adopt similar coverage policies, and there are now more equitable billing methods to make MAE services a vital part of therapy practice.

Mark R. Schmeler, PhD, OTR/L, ATP, is a faculty member at the University of Pittsburgh in the Department of Rehabilitation Science and Technology, and has more than 15 years of clinical, teaching, and research experience. He practices in the Center for Assistive Technology at the University of Pittsburgh Medical Center. He is co-chair of the International Seating Symposium, associate editor of RESNA's Assistive Technology Journal, and chair of their special interest group on wheeled mobility and seating. Schmeler can be reached via e-mail: .

Christopher D. Chovan, MOT, OTR/L, ATP, is an occupational therapist and RESNA-certified assistive technology practitioner. He has been practicing in the area of seating and wheeled mobility for almost 10 years, and has presented on the topic at more than 50 conferences, trade shows, and seminars. He is president of a therapy private practice that specializes in seating, positioning, and wheeled mobility, and has an adjunct faculty appointment with the Department of Rehabilitation Science and Technology in the School of Health and Rehabilitation Sciences at the University of Pittsburgh.