the aquatic therapist

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>>

Sometimes it's the air, not the water, that makes you sick in the therapy pool

Many aquatics professionals are hearing reports about swim meets where athletes have to queue up in the hallway because the natatorium air is too polluted to breathe.

Similarly, therapists are beginning to complain about the air quality in their therapeutic pools. After all, its the therapists who are breathing the stuff 4-8 hours a day. Worse, what if you have asthma? Or are pregnant? Are you at risk?

In the past, we've been focused on ensuring the cleanliness of our pool water; we have been worried about RWI (recreational water illnesses). Unfortunately, no one was thinking about the offgasing of chemicals and byproducts that tend to hover about 18 inches above the water's surface (right where your intake valve is!)

According to Robert Kappel, Siemens Water Technologies, the health issues relating to disinfection byproducts (DBPs) and indoor air contamination may soon overtake the concerns about recreational waterborne illnesses (RWIs).

Read more...

How to keep your therapy pool clean and RWI free: a monthly newsletter from the NSPF

Aquatic professionals now have a respected source for the most current information about pool and spa accident and illness prevention with the Prevention Advisor™.

This free monthly e-newsletter is published by the National Swimming Pool Foundation® (NSPF®) as a service to pool and spa operators, service technicians, health officials, and other professionals committed to staying abreast of key prevention topics. The Prevention Advisor allows NSPF to keep pool professionals up-to-date on the latest improvements until they are ready to re-certify.

Each month, the Prevention Advisor contains information which focuses on a specific subject such as health and safety information, regulations and legal topics, training opportunities, preventive maintenance tips, research findings, and other important subject matter.

Sign up to receive newsletter

Ask ARN: Must therapy pools supply lifeguards during aquatic therapy sessions?

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

 

Question: What kind of policy should we have regarding posting a lifeguard on duty at the pool? Are therapeutic pools held to the “public pool” standard?

Answer: There are over 100 bathing codes in effect in the U.S. and no two of them have identical wording concerning lifeguards. In most states, therapy pools are considered "public" pools and are subject to all the same codes and regulations as any other public pool in the state.

Some states have a “semi-public" or "special pool" or “therapeutic pool supervised by a licensed medical practitioner" category. Since surveillance requirements vary from state to state depending on the categorization, each practitioner should make himself aware of the requirements which pertain to his state or locality.

Regardless of whether or not a state code requires that lifeguards be posted, the facility is still required to provide a safe environment, and to provide rescue assistance and necessary First Aid.

The prevailing standard that public pools must hold to includes the following requirements:

• The standard of care in the industry (in the U.S.) is the "10/20 Supervision Rule". Trained and qualified lifeguards must be posted in a way that they can observe and scan their entire area of responsibility once every 10 seconds, and respond to and manage an emergency situation within another 20 seconds.
• Lifeguards should be properly dressed in uniforms (provided and paid for by the employer) and readily identifiable to patrons.
• At least two certified or licensed lifeguards should be in attendance at all public pools at all times the pool is in operation.
• Lifeguards should have no duties to perform other than the close general supervision of participants in water contact activities.
• Lifeguards should be alert, rotate to a new position at least once every 40 minutes, and be given frequent relief breaks from surveillance duties.
• The number of lifeguards should be adequate for the activities being conducted, the size and shape of the facility, and environmental conditions which might limit the ability to provide supervision.
• Lifeguards should be at least 18 years old, medically fit, have good eyesight, be physically capable of meeting the demands of the job, possess current certifications or licenses (in lifeguarding, CPR, and First Aid) from a recognized training agency, have adequate specific training for the facility, and be qualified and practiced in emergency procedures and other job aspects including use of rescue equipment (a minimum of four hours/month inservice training).

Source: Osinski A. Aquatic Therapy Listserv. Aquatic Consulting Services: San Diego, CA; 2001. For more information: Aquatic Consulting Services, Phone (619) 224-3100, Hotline (900) 446-6075 x 820. Web: www.AlisonOsinski.com

Ask ARN: Lightning storms and aquatic therapy pools

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

Question: Should we close our therapy pool during lightning storms?

Answer: The first place you should look is at your state code for swimming pools. To get a copy for your state, click here for state pool codes.

If there is nothing there, your state probably does not regulate the issue. You can then look to outside authorities.

For instance, here is a site on lightning safety and indoor pools.

Be aware that six states have recommendations or regulations for suspending indoor pool activities when under lightning threat: Delaware, North Dakota, South Dakota, Maryland, Rhode Island, and Michigan. Delaware’s state code reads "during electrical storms the use of a pool (indoor or outdoor) shall be prohibited."

Several large national groups describe building interior pool hazards (*) or have recommended indoor pool activity suspension (**) when nearby thunderstorms threaten. See:

National Athletic Trainers Assn.** (NATA)
www.nata.org (type "lightning" in search box)

National Collegiate Athletic Assn.* (NCAA)
www.ncaa.org/library/sports_sciences/sports_med_handbook/2002-03/1d.pdf

American College of Emergency Physicians ** (ACEP)
www.acep.org (type "lightning" in search box)

US Swimming, Inc. **
www.usa-swimming.org (type "lightning" in search box)

YMCA Services Corporation**
www.yservicescorp.com/Docs/Guidelines/LightningPoolGuide.doc

All pool buildings should be equipped with lightning protection as specified in the most recent version of National Fire Protection Association NFPA-780 Standard for the Installation of Lightning Protection Systems. Special attention should be paid to surge protection and bonding issues. A comprehensive inspection should be conducted by a qualified electrician every five years.