April/May 2000

The Changing Tide of Aquatic Therapy

By Ruth Meyer, Med, RKT, PMB

Getting reimbursed for aquatic therapy can be a challenge in this fluctuating industry, but documentation and understanding the coding process can help.

Aquatic therapy is a difficult field to be in today. As a practitioner who has been working in the aquatic therapy field for the past 20 years, I have struggled to receive third-party payor reimbursement and I have never been paid by Medicare or Medicaid. In the past 3 years, I have been moving away from the insurance paradigm and into the wellness arena. With people taking more responsibility for their own health, I see this as the future for aquatic therapy professionals.

With the changing health care environment, I have a few tips for aquatic therapy professionals who are trying to maximize their viability in the health care continuum:

• Staying in business depends on your ability to maintain contacts, obtain new referrals, and stay connected to the lines of communication within the insurance and health care industry.

• Owning a pool is not always a plus. It is an ongoing cost that requires regular maintenance and improvements. Utilities can significantly increase your monthly costs, and, typically, pool areas cannot easily be converted into other usable space.

• Whether you are working for a large rehabilitation facility or you are a small business owner, your accounts receivable must be up to date. The timely submission of bills with reports and daily notes is crucial.

• Moving to a cash-based practice—asking for payment at the time of service, forcing clients to submit their own bills to insurance companies—should be considered.

Documentation

Allen Ling, PT, owner of PT Innovations, El Cerrito, Calif, comments: “Aquatic physical therapy is a mystery to many payors and the best strategy is to use a combination of the protocol and matrix systems. Be sure to include protocols with any documentation that is being audited or reviewed. This will assist the reviewer in making sense of what you are doing. I did not help the Medicare reviewers, and I think that if I had included the protocols to explain what I did, it would not have been so traumatic. I incorrectly assumed they would hire qualified reviewers. Many of the nonsensical stuff that was reversed later had to do with aquatic physical therapy being defined as wound debridement for burn patients. A simple explanation of every procedure may have helped with the audit results earlier on. In the end I prevailed, but only after undergoing hearings and legal fees of $10,000.”

Send information to the insurance carrier as well as the involved physicians on your and your staff’s training and specialties. Make it clear that your clients are not just splashing in the water. Develop protocols for specific diagnoses, videotape your work, document improvements and changes, and interview patients postrehab.

Use your daily sheets to help easily document the specific aquatic activities performed, what equipment is used, how much resistance is generated, how fast the client is moving and through what range of motion (ROM), length of lever arm, position of the client in the pool, amount of water resistance, and intensity.

One of the toughest situations for aquatic therapists is overcoming a physician or payor’s negative experience with patients who received aquatic therapy from unskilled sources with little or no effect. Documentation is the key to overcoming this objection.

Coding

There seems to be some confusion concerning current procedural terminology (CPT) codes, which describe a procedure performed but do not distinguish who is performing the technique. Some states have very rigid licensing laws concerning who may perform specific techniques, although these licensing laws are different from the state regulations dealing with insurance reimbursement. Some states have Health Care Financing Administration (HCFA) intermediaries who interpret who may perform and get paid for aquatic therapy.

PTs most often use the term “aquatic physical therapy.” Those who are not PTs cannot legally use this term without violating state licensing laws. As a kinesiotherapist, I use the term “aquatic therapy.”

Aquatic therapy techniques predate HCFA’s health specific common procedures coding system. As a result, over the past 20 years, the code for hydrotherapy, which does not distinguish between techniques, has been used for aquatic therapy. The new code, 97113, still does not distinguish between the different types of techniques unless you design them yourself. Sometimes the differentiation is individual versus group, sometimes it is the duration of treatment, and, at other times, it is specific aquatic therapy technique. Unfortunately, there is not a national standard for coding aquatic therapy besides using 97113 or 95240. Minimal changes were made in July 1999 that resulted in the designation of 97022 for whirlpool and 97036 for Hubbard tank.

Diagnosis codes in some states will be the determining factor as to whether you will be reimbursed for aquatic therapy. Marilou Moschetti, PTA, Aptos, Calif, provided the following codes and reimbursement figures used in the payor-designated “rest of California” (areas that are outside of Southern California):

97110 Therapeutic exercises $21.67
97113 Aquatic physical exercises $23.50
97112 Therapeutic procedure, neuromuscular reeducation, balance, kinesthetic sense, posture, proprioception $22.32
97116 Gait training therapy $18.96
97150 Group therapeutic procedure $17.18
97140 Manual therapy $22.06
97124 Massage $17.20
97530 Therapeutic activities for functional performance $24.09

Many aquatic professionals use a qualifier when billing for aquatic therapy, possibly 97113-00 for aquatic evaluation, 01 for Bad Ragaz, 02 for aquatic exercise, 03 for Watsu®, and 04 for group exercise. With the form locator, 46 is used for 15-minute increments (>8 minutes and <23 minutes).

Referral and Evaluation

In many states direct referral is allowed when PTs receive their PT II status; however, it does not guarantee reimbursement. Typically, insurance companies will still require the primary care physician to do the visit and referral. Knowing your local regulations and which insurance carriers allow direct referral is crucial. Direct referral in some states allows for initial evaluation and 1 month of treatment prior to a physician referral.

Most insurance carriers will pay for one evaluation, so you may need to combine a land and an aquatic evaluation or use your first treatment session as an evaluation treatment. Be sure to check your referral; if it says for aquatic therapy only, you may need to do a specific aquatic evaluation Objective, quantifiable information is important, ie, ROM, manual muscle testing, repetitions performed in a unit time, heart rate (resting, exercise, and recovery), balance, gait pattern, standing or sitting tolerance, edema-pitting, or circumference.

Be very specific about your client goals and focus on activities that will assist in reaching those goals. Reevaluate regularly (every five visits, every 2 weeks, or every month, depending on the provider). Involve the client in all goal-setting sessions. If clients want a long-term program, incorporate some education into the treatment so they can function at a community pool. Develop a relationship with local pools so you have places to refer clients to for short-term memberships, which are sometimes covered by the insurance companies (3 to 6 months is the usual limit). Aquatic therapy programs can develop lifelong, valuable skills. They can certainly provide more than just a few therapy sessions before the client proceeds to rehab on land. We just have to prove it.

Ruth Meyer, MEd, RKT, PMB, is the owner of Aquatic Healing Services in Nashua, NH. She specializes in Watsu and be reached via email: watsunh@aol.com.

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