the aquatic therapist

Medicare rules for use of community pool - apply to private practice, physicians office, outpatient hospital or outpatient SNF

Just a reminder of a change that happened in Medicare policy last summer...

According to the CMS:

When therapy services may be furnished appropriately in a community pool by a clinician in a PT or OT private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider shall rent or lease the pool, or a specific portion of the pool. [Emphasis added]

The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider. The written agreement to rent or lease the pool shall be available for review on request. When part of the pool is rented or leased, the agreement shall describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies.

Other providers, including providers of outpatient physical therapy and speech-language pathology (OPTs or rehabilitation agencies) and CORFs, are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools.

Medicare Benefit Policy Manual- Chapter 15 – Covered Medical and Other Health Services (See Section 220C) (Revision 109, 08-07-09)

How frequently is aquatic therapy billed to Medicare Part B? Answers to statistical questions about aquatic therapy use

Inquiring minds want to know:

• How frequently is aquatic therapy billed under Medicare Part B?
  
• How often do private practice PTs use the code 97113? How about OTs?
  
• What setting is the most likely to bill for aquatic therapy?

Answers to these questions -- straight from CMS (click here for master document). Here are a few of the highlights. (From 2006; published Feb 1, 2008)

[Editor's note: Looking for more recent statistics? You can order the 2008 data from Medicare for $100. Download the BESS file here. Contains private practice data only.]

How big a percentage of Medicare Part B claims does “aquatic therapy” (97113) represent?

In 2006, aquatic therapy comprised approximately .9% of claims. It was the 14^th most frequently billed outpatient code behind:

• 97110 (therapeutic exercise) 33.03%

• 97140 (manual therapy) 11.37%

• 97530 (therapeutic activities) 9.52%

• 97112 (neuromuscular reeducation) 7.51%

• G0283 (electrical stimulation - not wound care) 6.23%

• 97116 (gait training) 6.01%

• 97035 (ultrasound) 5.82%

• 97001 (PT eval) 3.09%

• 97535 (self care management) 2.95%

• 97032 (electric stimulation) 2.23%

• 97526 (treatment of swallowing dysfunction) 1.70%

• 97150 (group therapy) 1.33%

• 97124 (massage) 1.23%
  

Which settings are the most likely to bill for aquatic therapy?

Obviously, therapists/physicians are more likely to use the procedure “aquatic therapy” in a hospital, outpatient rehab facility. or outpatient PT setting than in a SNF or home health setting. So, although the code 97113 represented less than 1% of all claims to Medicare Part B in 2006, it represented over 2% of all claims made by hospitals. More here

How much were providers reimbursed for aquatic therapy?

Although “aquatic therapy” represented less than 1% of all claims to Medicare B, it was responsible for 1.75% of all dollars reimbursed overall and over 2.3% of payments doled out to private practice PTs. Why? CPT code 97113 has a higher relative value (and thus a higher reimbursement rate) than many of the other codes on the list. More here

How frequently do private practice PTs bill for aquatic therapy? How about private practice OT?

In 2006, private practice PTs were over 3x more likely to bill for “aquatic therapy” than private practice OTs. More here

There's tons more info available... including the most commonly used ICD-9 codes, the average number of visits by ICD-9 diagnosis, and more. Click here for CMS outpatient therapy utilization document.

Read eSPLASH, the Aquatic Therapy Industry hotsheet

 
Nearly 5000 aquatic therapists get it every week. So why not you?

Here are just a few of the topics you missed...

12 Oct 2009: Billing for groups, WaterWay Babies, Multiple sclerosis and More!

21 Sept 2009: Medicare Denials, Swine Flu, TKR Proof, Adapted Showers and More!

14 Sept 2009: s/p TKR, Free CME, Grants for Pools, Pets vs. People and More!

7 Sept 2009: MRSA transmission, Neonatal hydro, HIV lawsuits and More!

17 Aug 2009: Vomit, Pool Yuck, Baby Asthma and More!

3 Aug 2009: Lower Back Pain, Blind Aquatic Therapy, Preschooler Pool Sessions and More!

Click here to read all the archives... or to sign up to get the hotsheet emailed directly to you every Monday.

Why are Medicare Intermediares giving aquatic therapy the cold shoulder?

As with all Medicare services, aquatic therapy must be medically reasonable and necessary in order for the provider to receive payment. Here are some of the most common reasons intermediares such as Cigna are choosing to deny aquatic therapy.

• Therapy services were provided to beneficiaries with no identified need for the use of this type of therapy. There was little evidence to support the need for use of a water based environment (i.e. buoyancy for un-weighting joints, resistance, and/or loss of motion).
• Services were provided for excessive durations of time per treatment session. In some cases aquatic therapy was rendered in excess of one hour.
• Aquatic therapy services continued for long periods of time (several months) in the absence of documented functional gains.
• Services were repetitive in nature and appeared to be for conditioning and overall fitness or maintenance.
• There was little evidence of transitioning the aquatic exercise program to a land-based exercise program to improve functional performance with every day activities.
• The programs provided in the pool setting were rendered in a group environment yet individual therapy was billed.

Source: Cigna Government Services: Aquatic Therapy

(Editor's Note: I would argue that the first reason is absurd. As long as equivalent or better results have been shown for working in water (and the research is mounting!), there should be no reason to have to forgo the pool for land. If the argument is that working in an "aquatic environment" is not functional, then I'd like to see the payer explain why they willingly reimburse for spinal traction or unweighted treadmill work).

Aquatic exercise statistics - how popular is non-swimming aquatic exercise?

Building an aquatic practice? Designing and patenting an exercise device for the pool? Or just writing that horrid research paper for PT school?

Well, you need up-to-date statistics. Here are a few arrows for your quiver:

Non-swimming aquatic exercise grew in popularity in the United States by almost 8% between 1998-2007. This is in stark contrast to other popular exercise options, including fitness swimming (which dropped 4.4%), aerobic dance (-17.3%), and fitness cycling (-23.2%)

In 2004, approximately 5.8 million people in the US participated in aquatic exercise. By 2007, this number had increased to over 7.2 million.

Aquatic exercise continues to appeal most to females in their middle or senior years, although that is mutating with the developing athletic programming focus. The average age of the quintessential aquatic exerciser is almost 47 years old.

When casual aquatic exercise participants are removed from the sample, the average age of the “frequent participant” (those who reported exercising in water over 100 days/year) ascends to 57+ years. Nearly 75% of aquatic exercisers are female.

Excerpted from Salzman, A. "Aquatic Aftercare and Wellness". In Becker, B, Cole A (eds). Comprehensive Aquatic Therapy. 3rd edition. Lippincott, Williams & Wilkins. Pending publication 2009. Statistics compiled in part from 2008 Superstudy of Sports Participation (Aquatic Exercise Slice).

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

Open Meme Friday: The Economy and Your Practice

First there was the mortgage bubble. Then there was the credit crunch. Now there are layoffs. While the experts are waiting for "the bottom", the rest of us are keeping a tight reign on our spending. Ordinarily, this should not effect the healthcare industry because consumers of HC services don't normally pay out-of-pocket for their care but we are starting to hear rumblings; rumblings of hospital cutbacks and rumblings of facility closures.

Taking in what the pundits think is one thing but we want to hear it from the aquatic street so we are turning on the comments this weekend to hear from you.  How has your aquatic therapy practice been trending the last few months? How does the economic downturn look in regard to your census? Have your referrals dried up? Have you had to let staff go? Or have your profits tracked even with last year or actually gone up? Contribute to this meme by clicking on the comments link below. The stories you tell may dictate how we all do business in the next 12-18 months.