How much does Medicare pay for CPT 97542?

Medicare allowed an average of $23.83 per service and paid $18.24 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $61.11, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 97542?

Evaluation for wheelchair, each 15 minutes. It was billed 56,811 times to 15,575 Medicare beneficiaries by 356 providers in 2024.

Does 97542 pay differently in an office than a hospital?

Yes. The allowed amount averaged $23.82 in an office setting and $29.71 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 97542 most?

Occupational Therapist in Private Practice, with 33,035 services from 200 clinicians. Next are Physical Therapist in Private Practice, Physician Assistant, Physical Medicine and Rehabilitation.

CPT 97542

Evaluation for wheelchair, each 15 minutes

$23.83Medicare-allowed amount per service, averaged across 56,811 services

Providers submitted

$61.11

Asking price, not received

Medicare allowed

$23.83

The fee schedule figure

Medicare paid

$18.24

Balance is patient coinsurance

Providers submitted an average of $61.11 for this code and Medicare allowed $23.83 — 2.6× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $18.24 (77%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $23.82
Hospital / facility: $29.71

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 56,761 services were billed in an office setting and 50 in a facility.

Services: 56,811
Beneficiaries: 15,575
Providers billing it: 356
Total allowed: $1,353,806

What Medicare pays for CPT 97542

Across 56,811 services billed by 356 providers to 15,575 beneficiaries, Medicare allowed an average of $23.83 per service. That is 3.6 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 97542

Specialty	Services	Beneficiaries	Avg allowed	Providers
Occupational Therapist in Private Practice	33,035	7,215	$23.94	200
Physical Therapist in Private Practice	18,861	5,918	$23.25	144
Physician Assistant	2,123	1,084	$23.19	2
Physical Medicine and Rehabilitation	1,317	602	$28.13	7
Nurse Practitioner	703	359	$23.14	1
General Practice	542	279	$27.30	1
Neurology	230	118	$29.82	1

97542 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
Virginia	4,687	$23.28	$17.75	24
Illinois	4,280	$23.59	$18.32	18
New York	4,111	$26.69	$19.00	28
Texas	3,737	$23.78	$18.52	27
New Jersey	3,662	$24.52	$18.36	27
California	3,614	$25.18	$18.24	14
Utah	3,364	$22.99	$17.29	7
Nevada	2,944	$23.18	$20.43	5
Missouri	2,924	$22.91	$18.24	21
Florida	2,643	$23.21	$18.24	20
North Carolina	2,057	$21.87	$17.53	13
Georgia	2,052	$23.39	$18.64	10
Minnesota	1,543	$24.01	$18.54	13
Iowa	1,405	$22.97	$16.91	3
Colorado	1,253	$24.55	$18.09	10
Washington	1,175	$25.82	$17.74	9
Pennsylvania	1,129	$23.06	$17.77	10
Michigan	1,001	$23.66	$18.55	8
Tennessee	916	$22.48	$18.16	13
Connecticut	893	$22.74	$17.54	4
Indiana	878	$22.92	$18.37	6
Wisconsin	878	$23.27	$18.80	5
Kansas	676	$23.00	$18.36	6
Oklahoma	595	$25.24	$19.99	2
Maryland	513	$25.10	$18.41	8
Montana	441	$24.12	$18.21	2
Kentucky	430	$21.98	$17.41	4
Mississippi	394	$23.30	$19.58	5
Nebraska	347	$22.93	$18.50	3
District of Columbia	250	$26.36	$18.44	2
West Virginia	246	$21.97	$17.65	3
New Hampshire	246	$24.75	$18.87	2
Massachusetts	245	$24.82	$19.23	3
Arizona	226	$23.67	$16.01	4
South Dakota	177	$24.92	$19.52	2
Arkansas	163	$19.93	$16.23	1
South Carolina	160	$23.86	$18.97	3
Oregon	146	$25.48	$19.18	2
New Mexico	94	$24.18	$19.88	1
Ohio	65	$24.15	$19.87	1
Alaska	59	$33.29	$19.50	1
Wyoming	46	$21.82	$16.99	1
Hawaii	42	$24.48	$18.74	1
Maine	32	$22.06	$17.27	1
Rhode Island	31	$24.19	$15.74	1
Louisiana	24	$22.18	$17.91	1
Alabama	17	$23.27	$15.65	1

Related codes

97530Therapy procedure$31.54
97535Training for self-care or home management$25.35
97597Removal of tissue from wound$74.53
97533Therapy procedure$52.00
97598Removal of tissue from wound$33.10
97550Caregiver training in strategies and techniques to facilitate the pati$51.87
97537Training for community or work reintegration$24.91

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.