Byline: Andrea Salzman, MS, PT
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?
Each payer publishes local coverage determinations (LCDs) or rules they expect for you to follow when billing under a given CPT code. If the payer has specifically stated that the provider must get wet, then they are within their rights to demand that your documentation show evidence that the therapist was in the pool.
But here is the rub. Payers are demanding documentation that the provider was in the water on the basis of "internal policy" or "standard practices". I would argue that this is improper. Not only is it not a "standard practice" for the therapist to be required to be in the water, many payers take the opposite position in their LCDs. Here are several examples of the language you will find memorialized in LCDs from different Medicare contractors.
Examples of LCD policies that specifically allow the therapist to be out of the water:
CONTRACTOR: Wisconsin Physicians Service Insurance Corporation
CPT Code 97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises:1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, and levels of assistance).2. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat their condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land based exercise or increase function. Documentation must be available in the record to support medical necessity.3. While they do not have to be personally in the water, the physician/NPP/clinician must at a minimum be personally present one-on-one next to the pool for any covered aquatic therapy services4. The medical necessity for multiple forms of hydrotherapy must be documented in the plan of care and medical records. Documentation must be made available to the Carrier on request.5. Supervision of a previously taught exercise or exercise program in the aquatic environment or performance of exercise in the aquatic environment that does not require the intervention/skills of the qualified provider is not covered. Performance of exercise in the aquatic environment independently without direct contact by the qualified provider is not covered.6. If the clinician provides aquatic therapy for more than one patient during the same time period, it is considered group therapy and is covered as such.7. This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).8. Exercises in the water environment to promote overall fitness, flexibility, endurance enhancing, aerobic conditioning, weight reduction, or for maintenance purposes are non-covered.Source: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=28531&ContrId=50&ver=23&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Minnesota&CptHcpcsCode=97113&bc=gAAAABAAAAAA&
CONTRACTOR: National Government Services, Inc.CPT 97113 - Aquatic therapy/exercises
Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.This procedure may be reasonable and necessary for the loss or restriction of joint motion, strength, mobility, balance or function due to pain, injury, or illness by using the buoyancy and resistance properties of water.Aquatic therapy may be considered reasonable and necessary for a patient without the ability to tolerate land-based exercises for rehabilitation. Aquatic therapy exercises should be used to facilitate progression to land based therapy and to increased function. The qualified professional/personnel auxiliary personnel does not need to be in the water with the patient unless there is an identified safety issue.Exercises in the water environment to promote overall fitness, flexibility, improved endurance, aerobic conditioning, weight reduction, or for maintenance purposes are non-covered.This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). If continued aquatic exercise is needed, the patient should be instructed in a home program during these visits. Lack of pool facilities at home does not make continued treatment skilled or reasonable and necessary. The home program may need to be carried out through community resources. Documentation must clearly support the need for aquatic therapy greater than 8 visits.
CONTRACTOR: Highmark Medicare Services, Inc.
Aquatic therapy with therapeutic exercises (CPT code 97113)
This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury. This requires direct (one-on-one) patient contact. However, the therapist does not have to be in the water. This code is to be used for any exercise performed in a water environment.
Documentation should include objective findings related to joint motion, strength, or mobility impairments (e.g., degrees of motion, strength grades, levels of assistance) and reflect the medical necessity of the treatment in a water environment. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy.
Do not report aquatic therapy (e.g., Hubbard tank, whirlpool), and the type of therapeutic exercise separately. Code ONLY the aquatic therapy with therapeutic exercise (97113). This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). It is considered not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).
If your local contractor is requiring you to show that the therapist was in the water with the patient, ask to see the LCD or written policy that states this coverage decision. It is unfair for a payer to deny care when their own written policies do not discuss any such requirements.
That said, just because you may be permitted to remain on the deck, doesn't mean you should. If it is your clinic's standard operating procedure to staff the pool with therapists wearing polo shirts, standing on the deck with clipboards, never entering the water, never able to enter the water... you may need to ask yourself some stirring questions about the quality -- and skilled nature -- of your care.
Great. I'm wrong all the time. Let's hear you make your best case for providing skilled care on the deck.