the aquatic therapist

Guest blog: Staying afloat - Tips for aquatic therapists

by Kelly Kilpatrick

It’s no longer an emerging trend, but aquatic therapy continues to struggle to find its niche in the realms of mainstream medicine.

There’s no doubting the fact that aquatic therapy is beneficial in recovering from surgeries, illnesses and injuries with the least amount of pain. Why? In water, the body is supported while allows for a low-stress environment during the healing process unlike on dry land where gravity tends to affect weight bearing activities.

But the tricky part for aquatic therapists may have nothing to do with the pool itself. Rather, therapists who choose to work in the water often must jump through additional hoops in order to get paid. Here are a few tips for aquatic therapists to help them stay afloat:

• You’re bound to have trouble with the reimbursement from some insurance companies and some local intermediares of Medicare. There are certain rules to be followed before the payment comes through, and if you’re not familiar with these, you can kiss the money goodbye. For instance, your documentation must support medical necessity and show that you worked 1:1 with the client in the pool.

• Think once, twice and many more times before you invest in your own pool and other treatment facilities. While it’s nice to have your own place, if your practice is not continuously lucrative, you’re going to be stuck with a white elephant and maintenance costs are going to hit the roof. And those energy costs are certainly not coming down anytime soon.
  
  
• Consider cash-based therapy if your patient caseload is not covered by insurance. Cash-based practices do best in states with direct access. Keep in mind that some states do not allow direct referrals while others do, so check if you need an evaluation by a physician. Keep a list of the insurance companies that do allow direct referrals.
  
  
• Diagnosis codes vary according to insurers, so make sure you use the right ones in your documentation. Some payers do not recognize the code 97113 although they do not have a problem with water-based treatment.
  
  
• Set goals for your clients and work on reaching those goals within the time limits. Find out early on if your clients want to continue with aquatic exercise even after they are discharged. If so, teach them a little more independence each visit rather than just telling them what to do.  

By-line:

This post was contributed by Kelly Kilpatrick, who writes on the subject of nursing schools online. She invites your feedback. Or checkout her website at www.nursingdegree.net. 

Why balance train in water & how to convert the Berg Balance Assessment into an aquatic challenge

Why balance train in water? Read the 2008 full text research which supports this idea (article is in Portuguese and English).

In the water, patients may be challenged beyond limits of stability without the fear of consequences of falling which are often present with land-based balance training. The environment leads to improvement in balance reactions which are translatable to land.

(Read Andrea Salzman's Converting the Berg Balance Test into an aquatic challenge)

 

Movement through water is affected by turbulence and viscosity. Water is more viscous than air, and resistance to flow through water is greater than resistance to flow through air. Thus, it takes more force to push through water molecules than to push through air molecules.

Additionally, the faster an object is pushed through the water, the more turbulence is created and this creates additional resistance to movement.

A body immersed is surrounded by a viscous fluid which retards the speed of movement. This viscosity prevents rapid falling and elongates the period of time in which a patient can respond to a shift of his center of mass outside his base of support.

Additionally, the natural end result of a loss of balance which is not corrected is a fall into a compliant fluid (water) and not a fall to a noncompliant solid (the ground). Thus, the patient may be challenged to move outside his base of support without fear of traumatic consequences.

This reduction in patient anxiety may encourage the patient to attempt tasks which he would not attempt on land. It becomes possible to elicit balance challenges which the patient has both time and mental confidence to combat. On land, without the assistance of such aquatic properties, the resultant balance responses may be incomplete or absent.

So, it makes sense that aquatic based balance training could lead to an improvement in balance on land.

Link to Andrea Salzman's adaptation of the Berg Balance Assessment into a 30 minute aquatic treatment for your balance patients.

2008 research source: Resende SM, Rassi CM, Viana FP. Effects of hydrotherapy in balance and prevention of falls among elderly women. Rev Bras Fisioter. 2008;12(1):57-63.

Great download: The APTA answers your frequently asked billing questions

Answers to these questions (PDF) and more:

[Editor's note: The APTA answer to the question about whether therapists must have exclusive use of a community pool for Medicare patients is no longer accurate. Since this audioseminar took place Medicare has changed its policy to allow therapists to use a PORTION of a pool for their clients.]

SAMPLE QUESTIONS ANSWERED IN THIS PDF:
Q: Is the 2008 therapy cap of $1810 the allowable rate or actual payment received?

Q: Why do the therapy caps not apply in outpatient hospital departments?

Q: Is it okay to offer Medicare patients an “aftercare” program if they use up the cap at a
reduced rate or flat fee? What if the PT or PTA is also certified as a Personal Trainer or
CSCS?

Q: If a Medicare beneficiary has therapy in an outpatient hospital department (exempt
from the cap) and later goes to a private practice, does the private practice have to include any money spent by Medicare at the hospital based facility?

Q: Does the Medicare program require a referral/prescription/order for outpatient
physical therapy services?

Q: Are physical therapists allowed to bill for the plan of care? Is the code the same as a
progress note?

Q: Does the 90 day recertification period apply to both Medicare A and Medicare B
residents in a SNF? Does the fact that we bill for the services provided to our outpatient
beneficiaries on the UB-04 form make a difference?

Q: Can you tell me if there are any Medicare regulations or policies on whether or not a
private practice can determine how many Medicare referrals they will take?

The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review

Don't you just love to be right? Who knew aquatic therapy was good for the patient with fibromyalgia? YOU KNEW! (Do the end-zone dance now).

 

ABSTRACT: Hydrotherapy is often used in the treatment of fibromyalgia syndrom (FMS), however there has been limited evaluation of its effectiveness.

The aim of this systematic review was therefore to examine the effectiveness of hydrotherapy in the management of FMS. AMED, BNI, CINAHL, The Cochrane Library, EMBASE, MEDLINE, ProQuest, PubMed, Science Direct and Web of Science were searched (1990-July 2006).

Key words used 'fibromyalgia' and 'hydrotherapy', 'balneotherapy', 'aqua therapy', 'pool therapy', 'water therapy', 'swimming', 'hydrogalvanic', 'spa therapy', 'physiotherapy', 'physical therapy' and 'rehabilitation'.

Searches were supplemented with hand searches of selected journals. Randomised controlled trials (RCTs) were assessed for methodological quality using the van Tulder scale.Ten RCTs met the inclusion criteria. Mean methodological quality was 4.5/9 on the van Tulder scale.

Positive outcomes were reported for pain, health-status and tender point count. There is strong evidence for the use of hydrotherapy in the management of FMS.

SOURCE:

McVeigh JG, McGaughey H, Hall M, Kane P. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008 Aug 27. [Epub ahead of print]

School of Health Sciences, Health and Rehabilitation Sciences Research Institute, University of Ulster, Newtownabbey, BT37 0QB, Northern Ireland, UK, j.mcveigh@ulster.ac.uk.

Ask ARN: What should I do if an insurance company won't pay for the aquatic therapy code 97113?

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.

Beat the CEU rush with our Last Gasp webinars coming Dec 08

Running out of time to get your 2008 continuing education credits? Don't like to travel?

This year, bypass the nightmare of smokey hotel rooms and embarrassing body searches by registering for our Last Gasp Aquatic Therapy eCourses instead.

Pick the topics (online poll)

Price is $199/webinar and includes:

• handouts,
• bibliographies,
• CEU credits for OTs, ATCs and PTs
• and more!

With a few clicks of a mouse, you can get up to 6 CEUs from the comfort of your own home or office by joining one of our four online webinars.

One veteran's efforts to re-open his community's therapy pool

Excerpted from Seattlepi.com Oct 2, 2008

Cyril Miller is an Army airborne veteran who lives by the airborne creed: "All the way and then some."

After being referred for aquatic therapy, he discovered that the VA pool had been closed since May 2007. He went to Stan Johnson, the new director of the VA Puget Sound Health Care System (in Washington state), with the question: "Why can't our government fix the therapy pool?"

The question was answered simply: The repairs cost more than $1 million and there are other priorities.

Read what he did next...

Why is your body falling apart after years in the therapy pool? Alison Osinksi to the rescue!

Aquatic therapy professionals ask us the same questions over and over. Alison Osinski to the rescue!

Here are links to all those (literally) burning questions about the effects of spending your days in water.

Exactly how does spending all those hours in the therapy pool affect your:

• Skin (short term)
  
• Skin (long term)
• Hair
• Eyes
• Ears
• Teeth
• Stomach
• Body temperature
• Swim Suit