Community First Health Plans is providing guidance on billing requirements for services performed by a Qualified Rehabilitation Provider (QRP) related to wheeled mobility system and wheelchair seating assessments and fittings.
Proper adherence to these billing requirements supports accurate claims processing and helps prevent claim denials or rejections.
When a Seating Assessment Is Required
A seating assessment is required for the rental or purchase of wheeled mobility systems or wheelchairs for members with conditions such as congenital or neurological disorders, myopathy, or skeletal deformities that require wheelchair use.
These requirements are consistent with criteria outlined in the Texas Medicaid Provider Procedures Manual (TMPPM) §2.6.9.1.2, Wheeled Mobility Systems.
Seating Assessment Requirements
Seating assessments must include measurements and specifications for the required mobility equipment and accessories.
Assessments must be completed by a licensed physician, occupational therapist (OT), or physical therapist (PT). A QRP employed by or contracted with the DME provider must be present and actively participate in all seating assessments, including those performed by a physician.
Upon completion, the QRP must attest to participation by signing the required seating assessment documentation.
Billing for QRP Participation – Seating Assessment
QRP participation in a seating assessment must be billed using:
- Procedure Code 97542 with Modifier U1 (QRP participation in seating assessment)
- Billed in 15-minute units, with a maximum of 4 units (1 hour)
The DME provider billing for the wheeled mobility system must submit the claim, and the QRP specialty must be listed as the performing (rendering) provider on the claim for all components of the wheeled mobility system, including the seating assessment.
Failure to include performing provider information may result in claim denial or rejection.
Billing for QRP Final Fitting
Final fitting services must be billed using:
- Procedure Code 97542 with Modifier U2 (final fitting of wheeled mobility system)
- Billed in 15-minute units, with a maximum of 8 units (2 hours)
The same QRP who participated in the seating assessment must be listed as the performing Provider. Procedure code 97542 U2 must be billed on the same claim as the wheeled mobility system procedure code(s) for reimbursement.
Note: All adjustments, modifications, and repairs within the first six months after delivery are considered part of the purchase price and are not separately reimbursable.
Performing Provider Billing on the 837P (5010) Claim
When billing a performing (rendering) provider on the ANSI X12N 837P (5010) professional claim:
- The performing provider must be identified at the service line level.
- Use the PRV segment in the 2420A loop.
Required PRV Segment Elements
- PRV = Provider Code
- PE = Rendering (Performing) Provider
- PXC = Reference Identification Qualifier for Health Care Provider Taxonomy Code
- Taxonomy code must match PEMS enrollment
Example (QRP taxonomy):
| 1 PRV*PE*PXC*247200000X~ |
Key Takeaway
Claims submitted without correct procedure codes, modifiers, unit limits, or performing provider information are subject to denial or rejection. Providers are responsible for ensuring all billing requirements are met prior to claim submission.
HHSC Resources
- Texas Medicaid Provider Procedures Manual (TMPPM)
- Durable Medical Equipment (DME) Handbook
- HHSC Durable Medical Equipment Policy and Billing Resources
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter