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24.5.26.4 Seating Assessment for Manual and Power Custom Wheelchairs
A seating assessment, which includes specifications for exact mobility/seating equipment and all necessary accessories, must be completed by a physician, licensed occupational therapist, or licensed physical therapist.
To request prior authorization for a custom manual/power wheelchair, a Wheelchair/Scooter/Stroller Seating Assessment Form must be completed by a physician or a licensed physical or occupational therapist using the procedure codes 1-97001 and 1-97003.
The following documentation must be provided:
• A seating evaluation and seating measurements, performed by a physician or a licensed occupational or physical therapist, which includes specifications for exact mobility/seating equipment, all necessary accessories, and how the client and/or family will be trained in the use of the equipment.
•Anticipated changes in the client's needs, anticipated modifications, or accessory needs, as well as the growth potential of the wheelchair. A wheelchair must have a growth potential, which must accommodate 20 percent of height and weight changes.
•Significant medical information pertinent to mobility and requested equipment including intellectual, postural, physical, sensory (visual and auditory), and physical status. Address trunk and head control, balance, arm and hand function, existence and severity of orthopedic deformities, as well as any recent changes in the client's physical and/or functional status, and any expected/potential surgeries that will improve or further limit mobility.
•A description of the current mobility/seating equipment, how long the client has been in the current equipment and why it no longer meets the client needs.
•Client's height, weight, and a description of where the equipment is to be used. Include the accessibility of client's residence.
•Manufacturer's retail pricing information, with itemized pricing including the description of the specific base, any attached seating system components and any attached accessories as well as the manufacturer's retail pricing information and itemized pricing for manually priced components.
If the wheelchair assessment form is completed by a physician, reimbursement is considered part of the physician office visit and will not be authorized using the above therapy procedure codes.
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