The Aquatic Resources Network gets questions from clinicians each day. We think everyone should learn from the answers!
Question: A certain insurance company has informed us that they do not cover for aquatic therapy code 97113. We are in the process of trying to talk with them and educate them but I was wondering what you thought about charging them 97110 instead even though they are still in the pool and we charge everyone else 97113. Is that ethical, legal?
Answer: It depends! What you need to find out is the following:
1. By not accepting the code 97113, is the insurance company stating that they will not accept any therapeutic services performed in the water? Or is the company refusing to recognize the code 97113?
If it is the later, then simply ask the insurer which code(s) it would like you to use. Many worker's compensation insurers do not recognize the aquatic therapy code. It's just a nomenclature issue, not a coverage issue. Typically, 97110 is the substitution of choice.
2. If however, the insurer has stated that it will not pay for any care which occurs in the water, this is another matter. Insurers have the right to deny payment for services which fall outside their coverage policies.
If the insurer has issued a policy decision to not cover aquatic therapy, it becomes a matter which is probably beyond your individual capacity to alter. Organizations like the APTA tackle issues like this by attempting to demonstrate the evidence which supports the medical necessity of such services.
3. Finally, if the insurer does not have a specific policy in effect which denies coverage, perhaps the denial is a misunderstanding. Use logic in your discussion with the insurance company. Is the company taking on the decision-making role of the therapist?
In essence, by telling a therapist he or she cannot perform aquatic therapy, the insurance company is removing your ability to choose the right care for your patient. Would they tell you that you are not allowed to treat a patient lying down (to unload the spine)? Not allowed to perform progressive resistive strength training? Not allowed to dim the lights to decrease the amount of sensory input?
An insurer would not presume to do so on land... why would it become acceptable in the water? Often times it is because the insurer believes that aquatic therapy is something new or experimental in nature. Explain that in your case it is simply PT (or OT).... in the water.
Conclusion
That said, if the insurance company understands all that and still
refuses to pay, you cannot ethically "hide" the nature of your treatment
by coding it as 97110.
Think of it this way. Your documentation must support your care. You must address the fact that you are working in a therapy pool. If the insurer has explicitly explained that this is not reimbursable, the only way you could "get away with" submitting a claim is by coding in disguise. This will not fly and will bite you in the rear if you ever get audited. As it should.
Instead, try showing your insurer that other insurance companies have accepted aquatic therapy as medically necessary. For one example, check out Aetna's policy reversal. They now acknowledge that aquatic therapy can be medically necessary for musculoskeletal disorders.
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