Blue Cross Blue Shield defines medical appropriateness for aquatic therapy

Insurance companies are starting to establish limits on what they consider appropriate use of interventions such as aquatic therapy.

And although not all insurances treat CPT 97113 (aquatic therapy) the same, it is helpful to see what kinds of restrictions are working their way down the pike.

Here is an example of what Blue Cross Blue Shield of Tennessee considers appropriate use of aquatic therapy, including some "samples" of clinically-appropriate patients.

MEDICAL APPROPRIATENESS

• Aquatic therapy is considered medically appropriate for ALL of the following criteria:

  • The service is performed under the direct supervision of a licensed physical therapist with a physician's order
    

  • The therapeutic interventions rendered are directly related to a written treatment regimen that includes goals approved and signed by the physician
    

  • The individual must have impairments, functional limitations or disabilities that can be minimized or eliminated with aquatic therapy
    

  • The individual must be able to benefit from the unique properties of water (i.e., buoyancy, hydrodynamics, and hydrostatic pressure)
    

  • An individual selected for aquatic therapy must be unable to safely participate in a physical therapy program that is totally land based due to weight bearing restrictions, severe weakness or other considerations
    

  • The documentation must support the necessity of this intervention
    

  • The aquatic therapy rendered must require the skills of a physical therapist
    

  • A qualified therapist is physically present and actively involved in the treatment (Note: Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements.)
    

  • The aquatic therapy services rendered are considered acceptable standards of medical practice for the individual's condition.

ADDITIONAL INFORMATION

An individual may receive aquatic therapy on the same date of service as land based therapy. However, there should be an evident trend away from aquatic therapy and towards a fully implemented land based program.

Clinical Examples of Skilled Aquatic Therapy:

• An individual with arthritis who cannot ambulate on land because of the inability to use an assistive device, but who can begin walking in the pool.

• An individual who recently had a total hip replacement with weight bearing restrictions who has difficulty following these precautions on land and who needs to begin progressive strengthening of the leg.

• An individual with Guillain Barré or multiple sclerosis who is too weak to exercise on land but who can move in the pool with a buoyancy assist device.

Source: Blue Cross Blue Shield of Tennessee Medical Policy Manual