Provider Notice issued 11/17/14

Billing for Assessment Required by DME Form 3701H, Seating/Mobility Evaluation

This notice clarifies the procedure codes billable by physical and occupational therapists for the assessment that is required as part of a power mobility device (PMD) or custom manual wheelchair request.

The HFS 3701H, Seating/Mobility Evaluation (pdf), contains questions that must be completed by a licensed physiatrist or physical or occupational therapist. The therapist should not have any affiliation with the DME provider; the manufacturer of the recommended equipment; or the patient’s long term care facility. Therapists may bill CPT codes 97001 (PT Evaluation) or 97003 (OT Evaluation) for the services associated with that evaluation. The Therapy Crosswalk, part of the Therapy Fee Schedule, has been modified to crosswalk CPT code 97542 – Wheelchair Management (e.g., Assessment, Fitting, Training) to procedure codes 97001 (PT Evaluation) and 97003 (OT Evaluation) for the purposes of completing the seating/mobility evaluation requirement.

Evaluation codes billed by the therapist for the PMD or custom manual wheelchair assessment do not require prior approval.

Note: The billing instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs), and Care Coordination Entities (CCEs), and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any care coordination plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements, as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults .

Any questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs