Eli's Rehab Report

Published on Wed Aug 04, 2004 PDF

From skill versus unskilled therapy to the use of public pools, our coding specialists give you the scoop on 97113

If one of your rehab patients recently underwent total hip, knee, shoulder or elbow arthroplasty, you may be facing aquatic therapy claims. But you won't find yourself in deep water if you familiarize yourself with our expert tips.

During aquatic therapy (97113, Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises), practitioners use the therapeutic properties of water -- such as buoyancy and resistance -- to assist patients who are undergoing postoperative extremity (joint) rehabilitation.

The following five frequently asked questions and expert answers can help dilute coding confusion and avoid denials.

1. What Constitutes Skilled Versus Unskilled Aquatic Therapy Interventions?

If you want to collect reimbursement for 97113 every time, you should ensure that your therapist performed the aquatic therapy on patients who meet the insurers' criteria, and confirm that the documentation proves that the interventions are truly skilled.

Remember it this way: "Skilled therapy is when the therapist is actually one-on-one with the patient, and unskilled is when he or she is not," says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

For example: If a patient with arthritis cannot walk on land because of her inability to use an assistive device but can begin walking in the pool with the therapist's one-on-one help, the therapy qualifies as skilled. The patient benefits from aquatic therapy because of the water's unique properties that ease the burden of her treatment.

However, if a patient participates in an arthritis association community exercise program in order to maintain function rather than improve it, insurers would deem this type of aquatic therapy nonskilled.

2. What Do Carriers Require Before You Report 97113?

When the patient first presents to your practice, you should call the patient's insurer to determine whether her insurer will reimburse your practice for aquatic therapy. You may want to ask if they accept 97113 and request precertification if possible. If the patient's insurer does not cover aquatic therapy or denies the appeal, you can alert her so she can decide whether she wants to pay out of pocket.

Keep in mind: "A screening is usually done before a full-blown therapy evaluation (97001-97004) to determine if the patient is a candidate for a full evaluation and subsequent treatment," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director of the CRN Institute, an online coding certification training center. During the screening, the therapist decides whether aqua therapy benefits the patient more than land-based therapies. Conditions such as open wounds or a fear of water might preclude aquatic therapy.

Remember: Most carriers only reimburse one therapy evaluation for the patient for each episode of care per diagnosis. The therapist should perform this evaluation on land -- not in the pool -- by testing strength and range of motion, Jandroep says. Often, a therapist provides aqua therapy as a transition to land-based exercise and functional activities.

3. How Can We Differentiate Between Aquatic Therapies?

The guidelines for 97113 require that a physician or therapist perform the service with direct or one-on-one patient contact and that you bill in 15-minute increments. However, some aquatic therapy techniques may not fall directly under 97113, making it difficult for coders to determine the appropriate code.

For example: Bad Ragaz Ring Method describes a combination of proprioceptive neuromuscular facilitation (PNF) techniques and aquatic therapy. "This technique incorporates elements of land-based therapies," Jandroep says. Most experts recommend that you code it as 97113 rather than the similar 97112 (Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception).

Why? You can collect reimbursement for both, but most carriers request that you use 97113 because Bad Ragaz takes place in water and therefore constitutes aquatic therapy, whereas insurers may deny 97112 because the patient performed aquatic exercises rather than standard PNF. Make sure to ask your insurers whether they recommend a standard code for billing Bad Ragaz.

4. If We Use a Public Pool for Aquatic Therapy, Can We Still Bill Medicare?

Medicare allows therapists to use a community-center pool for aquatic therapy (97113, ... aquatic therapy with therapeutic exercises), but the pool must be exclusive to the therapist during the therapist's hours of operation, says Andrea Salzman, MS, PT, owner of the Aquatic Resources Network and Concepts of Physical Therapy in Amery, Wis.

According to CMS Pub. 100-02, Medicare Benefit Policy Transmittal 5, the practice must "rent or lease the pool for those hours, and use the pool during that time would have to be restricted to the therapist's patients, in order to recognize the pool as part of the therapist's own practice office during that time."

Therefore, if other swimmers who aren't the therapist's patients swim laps during the therapy session, you cannot bill Medicare if you use the pool for aquatic therapy during that period.

5. How Should We Code Aquatic Therapy That We Perform in Group Sessions?

Keep in mind that you should not bill aquatic therapy with therapeutic exercise (97113) if your documentation doesn't prove that the therapist and patient had one-on-one contact. For example, if an instructor directs an aqua aerobic class with more than one patient from a distance, most carriers would not consider it a necessary -- or reimbursable -- service.

However, when the therapist provides one-on-one contact with patients in a group format, you would code 97150 (Therapeutic procedure[s], group [2 or more individuals]) for each member in the group. Be sure to support this claim with appropriate documentation.

For example: Patients with arthritis or fibromyalgia can benefit from group therapy sessions. Unlike an aqua aerobics class, these sessions provide a means of routine physical activity as well as a support system and sounding board. Your documentation should include specific aquatic activities, the equipment used, and the progress toward pre-established goals (such as range of motion, frequency of repetition, intensity of effort, and duration of exercise).