Question: We recently received a request from our Medicare Contractor asking for documentation that verified that the therapist was in the water during aquatic therapy session. We have never had this request before.
Most of our sessions, the therapist is in the water, but sometimes she is not. Under neither circumstance do we specifically document the location of the therapist. Is this a valid restriction or reason for denial? Does the therapist have to be in the water for it to be considered skilled care. Help!
Answer: OK, let's tease out the two issues being discussed here.
Skilled versus Unskilled Care.
First, is the care "skilled"? The answer is: it depends. Certainly, a therapist who remains on the deck for part of a session is not automatically providing "unskilled" care. In fact, here are some examples of situations that I would argue the therapist should position him or herself on the deck specifically in order to increase the caliber of care provided:
- A sports-medicine therapist stands on deck in order to throw a ball to wide-receiver client while the receiver runs against a progressively resistive current. The therapist needs to be on deck to position himself quickly in different locations to alter the angle and direction of throw and to alter the current speed rapidly.
- A pediatric therapist works with a child who is learning to get in/out of pool independently. The therapist positions a mat on the deck and assists the child in performing the pool exit by being positioned on deck.
- A geriatric therapist performs gait training with a patient with a total knee replacment. The patient has been vetted for safety, and the therapist hops out of pool and stands on deck to better visualize the patient's knee extension during the gait cycle.
- The therapist teaches a complicated exercise to a patient with spatial-relations problems. The therapist gets out of pool and stands on deck in order to demonstrate the exercise or activity better.
These are just samples. There are a hundred reasons to hop in and out of the pool each day. The question becomes more troubling when the therapist never gets in... and never has the capacity to.
I would argue that it's one thing if the therapist is wearing a bathing suit and making choices on a moment-by-moment basis. "Do I get in?" "Should I hop out?"
However, if the therapist is fully dressed, then the intention is clear. There will be no opportunity to get in the water, even if the occasion arises. Safety issues aside, I would challenge the readiness of any therapist to provide skilled care if there is zero ability to get in the pool during the session. Most therapists would -- at a minimum -- agree that there are times in almost every session that the care provided would be enhanced by being in the water. For that to happen, the therapist has to be in a bathing suit, ready to get in.
Billable Versus Non-Billable Care.
Let's assume for a minute that the care you are providing is skilled. There is a reason for you to be in the pool when you are in... and an equally compelling reason to be out of the pool when you are out. In both environments, you are serving a medically necessary function.
The care might still not be billable. WHY?