ModifiedNew York State Department of HealthPolicy N/A

Update to Reimbursement for Wheelchair Evaluations

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This policy updates Medicaid fee-for-service reimbursement for wheelchair evaluations billed with CPT code 97542. It applies to appropriate practitioners and establishes a single reimbursement rate regardless of place of service, while preserving the existing utilization limit and outpatient clinic rates.

Policy Summary

PayerNew York State Department of Health

PolicyUpdate to Reimbursement for Wheelchair Evaluations

Policy CodePolicy N/A

Change TypeModified reimbursement rate and place-of-service fee structure

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionBill CPT code 97542 using the single general reimbursement fee regardless of whether the service is provided in a facility or non-facility setting.

SourceLink

POLICY UPDATE CHANGES

Reimbursement for CPT code 97542 is revised from $28.02 to $44.58 per 15-minute unit.

CPT code 97542 reimbursement no longer varies based on the location where the service is provided.

$44.58New reimbursement per 15-minute unit

$28.02Previous reimbursement per 15-minute unit

2 every 5 yearsAllowed frequency

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ModifiedNew York State Department of HealthPolicy N/A

Update to Reimbursement for Wheelchair Evaluations

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Sign up for all New York State Department of Health policy alerts

Know when New York State Department of Health releases new policies or updates existing guidance.

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Policy Summary

PayerNew York State Department of Health

PolicyUpdate to Reimbursement for Wheelchair Evaluations

Policy CodePolicy N/A

Change TypeModified reimbursement rate and place-of-service fee structure

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionBill CPT code 97542 using the single general reimbursement fee regardless of whether the service is provided in a facility or non-facility setting.

SourceLink

POLICY UPDATE CHANGES

Reimbursement for CPT code 97542 is revised from $28.02 to $44.58 per 15-minute unit.

CPT code 97542 reimbursement no longer varies based on the location where the service is provided.

$44.58New reimbursement per 15-minute unit

$28.02Previous reimbursement per 15-minute unit

2 every 5 yearsAllowed frequency

Wheelchair Evaluation Reimbursement Criteria

For dates of service on or after January 1, 2026, CPT 97542 is reimbursed under the following criteria:

ALL of the following

Bill CPT 97542 for evaluation for wheelchair, each 15 minutes.
The reimbursement rate is $44.58 per unit, replacing the previous fee of $28.02 per unit.
The service is provided by an appropriate practitioner, with a single general fee paid regardless of place of service or whether the setting is facility or non-facility.
Reimbursement for outpatient clinics, including hospital outpatient departments (OPDs) and diagnostic and treatment centers (D&TCs), remains unchanged.
Do not exceed the frequency and unit limits for CPT 97542.
The service is allowed twice every 5 years, with a maximum of 8 units per occurrence.

Billing and Reimbursement Details

Allowed frequency

Allowed frequencyTwice every 5 years

Maximum units

Maximum units8 units each

Previous fee

Previous fee$28.02 per 15-minute unit

New fee

New fee$44.58 per 15-minute unit

Required Billing Action

Billing Rule

Bill CPT 97542 at the revised general fee

For dates of service on or after January 1, 2026, bill CPT 97542 at the single general fee of $44.58 per 15-minute unit, regardless of facility or non-facility place of service. Observe the existing utilization limit: the service is allowed twice every 5 years, with a maximum of 8 units each.

CPT 97542: Evaluation for wheelchair, each 15 minutes
Allowed frequency: twice every 5 years
Maximum: 8 units each
Outpatient clinic reimbursement rates, including hospital outpatient departments and diagnostic and treatment centers, remain unchanged

Reimbursement Definition

General fee

General feeA single general reimbursement fee applies to all appropriate practitioners regardless of the place of service.

Policy Summary

PayerNew York State Department of Health

PolicyUpdate to Reimbursement for Wheelchair Evaluations

Policy CodePolicy N/A

Change TypeModified reimbursement rate and place-of-service fee structure

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionBill CPT code 97542 using the single general reimbursement fee regardless of whether the service is provided in a facility or non-facility setting.

SourceLink

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