the aquatic therapist

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.

How do I prepare my therapy pool for Swine Flu (H1N1)?

Yes, human-to-human transmission of H1N1 virus can occur. Even at your pool.

Transmission is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus.

From the NSPF: What actions should pool operators take at their aquatic facility?

Currently there is no evidence suggesting inactivating the H1N1 virus would be different than other flu viruses. Therefore, continuing to maintain the pool water within the recommended levels for pH and disinfectants should inactivate the viruses. Vomit incidences should be treated the same as always, follow guidelines on the attachment.
www.nspf.org/Documents/cdcarticles/cdcbloodandvomit.pdf


Viruses are transmitted in areas outside of pool water and other surfaces such as restrooms, door handles, and chairs. Follow CDC recommendations of 10% bleach solution to wipe these and other features down. For guidance on cleaning up bodily fluids on inanimate objects download:
www.nspf.org/Documents/cdcarticles/cdcbodyfluiddeck.pdf

From the CDC: Vomit and Blood Contamination of Pool Water

The most common germs spread through recreational water are germs that cause diarrheal illnesses and skin rashes. These are spread by swallowing water contaminated with feces or by skin exposure to contaminated water. Pool water is unlikely to spread illness.

Vomit in Pool Water

Vomiting while swimming appears to be a common event. Often, vomiting is a result of swallowing too much water and, therefore, the vomit is probably not infectious. However, if the full contents of the stomach are vomited, follow the guidance in these Q & As:

Q: What germs are likely to be spread by vomit?

A: Noroviruses (also known as Norwalk-like viruses)

Q: Assuming that norovirus is in the vomit, what should I do?

A: Respond to the vomit accident as you would respond to a formed fecal accident, using CDC's recommendations. The time and chlorine level combinations needed to kill noroviruses and Giardia are similar. Since killing Giardia is the basis of CDC’s formed fecal accident response recommendations, this protocol should be adequate for disinfecting a potentially infectious vomit accident.

Blood in Pool Water

Germs (e.g., Hepatitis B virus or HIV) found in blood are spread when infected blood or certain body fluids get into the body and bloodstream (e.g., by sharing needles and by sexual contact). CDC is not aware of any of these germs being transmitted to swimmers from a blood spill in a pool.

Q: Does chlorine kill the germs in blood?

A: Yes. These germs do not survive long when diluted into properly chlorinated pool water.

Q: Swimmers want something to be done after a blood spill. Should the pool be closed for a short period of time?

A: There is no public health reason to recommend closing the pool after a blood spill. However, some pool staff choose to do so temporarily to satisfy patrons.

Source: www.healthyswimming.com

Check for existing guidelines from your local or state regulatory agency before use. Healthy Swimming recommendations do not replace existing state or local regulations or guidelines.

The Lightning Controversy: A Rebuttal

In November, we reported in our eSplash newsletter that Aquatics International was questioning the policy of closing indoor pools during an electrical storm. Turns out that article has touched off a, err, firestorm with the National Lightning Safety Institute (NLSI) who have sent us a letter rebutting AI's claims. With all the experts in a tumult, what's a pool director to do?

Read the Aquatic International article here then the NLSI retort below before making up your own mind.

Lightning and Indoor Pools:  A Reply to Aquatics Resources eSplash Newsletter 17 Nov 2008*

By Richard Kithil, President & CEO, NLSI

Background: In May 2003, NLSI co-authored Lightning and Aquatics Safety: A Cautionary Perspective for Indoor Pools. Before and since that time, many national aquatics groups have followed our recommendations. We suggest, in brief, that safety is the prevailing directive and that pool activities should be suspended at the first signs of thunder or lightning. A contrary opinion has appeared in Aquatics Resources eSplash newsletter dated 17 Nov. 2008. The purpose of our reply is to discuss the topic with regard to comments made by the authors of the above newsletter article.

It is correct that national statistics omit reports of deaths from lightning to people in indoor pools. That’s good news. However, there are many reports of lightning deaths in bathtubs as well as reports of injuries to people indoors in direct and indirect contact with water (kitchen sink, laundry room, bathroom, etc.). The agencies that cause these incidents can be traced to energized circuits. This means copper water pipes, electrical service lines, and other conductors that carry some component of lightning’s energy. It seems reasonable to NLSI that the potential for lightning incidents to people in indoor pools does exist.

The eSpalsh [sic] article contains several errors that should be discussed. The National Electrical Code (NEC) does NOT refer in any way to pool closures or any type of enforcement or any legal consequences. The presence of a lightning protection system does not bring with it any certainty of immunity from death, injury, fire, or other consequences. People in contact with, or adjacent to, conductive circuits may become lightning victims regardless of grounding, bonding, shielding, surge protection, air terminals, etc. The National Collegiate Athletic Association (NCAA) does not refer to pools specifically. However, it does contain the warning: “avoid using the shower or plumbing facilities and contact with electrical appliances during thunderstorms.”

The bottom line: liability issues. There are nationally published recommendations for evacuating pools during thunderstorms. Those guidelines are based upon very conservative "safety first" principles. These admonitions do not have the force of law. However, they address a well-known duty-to-warn concept. Failure to provide safe activities and failure to comply with recognized national safety measures may bring with it liability issues. The choice is yours.

*Aquatic Resources Network (eSplash) Editor's Note: Dear reader. As you may realize, the article referenced by the NLSI was published by Aquatics International magazine and not by us. We merely linked readers to their online article. So, as much as we appreciate being at the middle of the storm, we can't take credit for the controversy! We've pointed this out to the NLSI, but so far, the website retort remains as is.

What to do if you are not getting the weekly eSplash (aquatic therapy industry newsletter)

Aquatic therapy gurus,

Many of you who signed up for our Aquatic Resources Network weekly eSplash have told us you are still not getting it. This may be because the email has photos/graphics which can tend to plop it into your spam folder.

To make it even easier, we took all the back issues and put them on the web.

For archived copies, go to:

http://archive.constantcontact.com/fs054/1102184430637/archive/1102261598185.html

Here are a few topics we've covered recently:

• 2 second test to determine if you are suffering from low-grade chronic dehydration
• Why Medicare changed their mind about community pool rental exclusivity
• What to do if your payers don't recognize aquatic therapy
• Sensory integration tips for pediatric therapists... and much more

Andrea Salzman, MS, PT
Aquatic Resources Network
www.aquaticnet.com

Feeling poorly? It just might be a chronic, low-grade case of dehydration

Unfortunately, thirst isn't always a reliable gauge of the aquatic therapist's need for water.

Instead, take the runner's test. Long distance runners have learned that a quick look back into the toilet bowl after peeing can give them a heads-up as to their hydration status.

Clear or light-colored urine? You're well hydrated.

But if you're seeing dark yellow or amber colored urine (see photo above!), you're simply not getting enough to drink.

Immersion causes the body to excrete more fluids. The more time you spend in the water, the more fluid you lose.

You've got to drink more. A lot more. Or you're going to develop a chronic case of "feeling old" before your time.

Mild to moderate dehydration is likely to cause:

• Dry, sticky mouth
• Sleepiness or tiredness
• Thirst
• Decreased urine output
• Few or no tears when crying
• Muscle weakness
• Headache
• Dizziness or lightheadedness

Source: Mayo.com

Other reasons for dark urine...

Questions about the Pool and Spa Safety Act? Here are your answers

Did you miss the Aquatics International webcast on implementing the Pool and Spa Safety Act?

Experts from CPSC, APSP and other industry pros discussed the Act in a roundtable discussion. Here is the Q&A session from registered participants to some of the questions asked and answered.

Note: We have not received any response from the CPSC to our questions about whether therapy pools must comply with this act. We will keep you posted, but for now, assume that you must even though therapy pools are not always considered "public pools" by the states.

It's a "best practice" issue even if it isn't the law.

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.

How many people comprise an aquatic group for "Group therapy" under Medicare

After our last posting, we have had several questions on "How many patients can be treated under the 'group therapy' code at one time in an aquatic environment?"

The response to the question is "there are no guidelines for the number in group therapy for outpatients, either aquatic or land based rehab."

Read more with this Medicare Advisor article.

ASK ARN: Can I bill CPT code 97113 (aquatic therapy) when treating 2 or more people in the pool at once?

The Aquatic Resources Network gets questions from clinicians each day. We think everyone should learn from the answers!

Question: If I work with 2 Medicare patients in the pool at the same time, is that considered group therapy or 1:1 therapy?

Answer: It depends! The group therapy code (CPT Code 97150) can be applied to different situations under the Medicare program.

Group therapy scenario #1: The therapist simultaneously treats two or more* patients whose conditions or treatment have a common, unifying element. This scenario describes a traditional group, for instance, a group of arthritis patients.

Group therapy scenario #2: The therapist simultaneously treats two or more* patients whose conditions or treatment have no common, unifying element. This scenario describes any situation where the therapist is working simultaneously with more than 1 patient at a time, even if each patient has his/her own specific treatment plan.

So, is it ever possible to bill for 1:1 care under the "Group therapy scenarios" listed above? Yes.

Here's how. It is possible to add-up the minutes spent with each individual patient and bill for these services with an appropriate 1:1 code if the 1:1 time requirements are met.

So, if you are treating 2 people in a 60 minute time period, you are permitted to charge each patient for the time you treated him/her individually. However, the total amount of time billed for the 2 people can not exceed the time you, the therapist, spent (1 hour).

Example #1: Say you saw Patient A from 9-9:15 and again from 9:30-9:45, you could bill Patient A for 2 units of aquatic therapy (97113). If Patient B was only seen 1:1 from 9:15-9:30, you could only bill him/her for 1 unit of aquatic therapy, even if you were in the pool until 10:00.

Example #2: Say you saw Patient A for 5 minutes, then Patient B for 5 minutes, then Patient A for 10 minutes (and so on for the hour span), it is still permissible to bill using the 1:1 code. You must, however, be able to verify the time spent with each person.

Example #3: Say you have 3 people in the pool from 9 to 10:00. You work with Patient A for 15 minutes, Patient B for 15 minutes and Patient C for 15 minutes -- and then you decide to bill each person an additional 97150 (group therapy) code for the remaining 15 minutes in order to get a higher reimbursement. Medicare would have problems with that. Why? Because it wasn't truly a group therapy session. It was unstructured time.

In contrast, if you had some sort of group aquatics class (for instance) and then everyone worked 1:1 with you for an additiona; 15 minutes of aquatic therapy, that would be a more legitimate use of these 2 codes together. [Note: You would need to use a -59 modifier in order to inform Medicare that the group therapy and aquatic therapy occurred separately.]

The APTA publishes an amazing resource online entited Group Patient Therapy Scenarios [1].On this site are 8 concrete examples of how a physical therapist/PTA should bill for his or her time when working with multiple people during a given time frame.

[*NOTE: Although Medicare used "2-5 people" to determine a reimbursement rate for group therapy, there is no cap to how many people can be treated at once with the group code as long as you are providing skilled care.]

Reference
1. American Physical Therapy Association. Group Patient Therapy Scenarios. APTA; Alexandria, Virginia; As seen on the APTA website July 25, 2005. <<www.apta.org>>