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Reminder of Seating Assessment Benefits for Texas Medicaid

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This is a reminder that, when appropriate, providers may submit claims for reimbursement on the same date of service for the following procedure codes:

  • A seating assessment (procedure code 97542)
  • A physical therapy evaluation (procedure codes 97161, 97162, or 97163)
  • An occupational therapy evaluation (procedure codes 97165, 97166, or 97167)
  • A physical or occupational therapy re-evaluation (procedure codes 97164 or 97168)

Note: Providers must document distinct start and stop times for each service to confirm that there was no overlap with the services performed.

Fee-for-Service Claims System

If the provider bills the seating assessment on the same date as the therapy evaluation or re-evaluation in the fee-for-service (FFS) claims system, Texas Medicaid will deny the therapy service. The provider must then appeal the claim denial and submit the required documentation showing the different time frame that each service was performed.

During the appeals process, a utilization reviewer or medical director (if necessary) will review the claims to decide whether both services can be paid on the same date.

Resources

Providers can access the Texas Medicaid & Healthcare Partnership (TMHP) Learning Management System (LMS) to review the training published in February 2025 on durable medical equipment (DME) specific to wheeled mobility systems.

Providers can refer to the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.17.2, “Wheeled Mobility Systems,” and subsection 2.2.17.10.1, “Prior Authorization,” for additional information.

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

For more information, call the TMHP Contact Center at 800-925-9126.