Eli's Rehab Report

Published on Mon Apr 17, 2006 PDF

Question: We often use a whirlpool to help cleanse patients'  wounds. Our carrier recently told us that we used this modality too frequently for one particular patient and that it expects us to combine the whirlpool treatment with therapeutic activities. Should we appeal?


Alabama Subscriber

Answer: Most likely, yes. Although some payers require therapists to limit modalities (97010-97028) to only 25 percent of a patient's total rehabilitation service hours, carriers usually make exceptions for wound care treatment.

The policy for Blue Cross and Blue Shield of Alabama states, "The use of modalities as stand-alone treatments is rarely therapeutic and usually not required or indicated as a sole treatment approach to a patient's condition .... Therefore, a treatment plan should not consist solely of modalities, but include therapeutic procedures."

But the policy does include a caveat, which states, "Examples of exceptions are wound care or when a patient is unable to endure therapeutic procedures due to the acuteness of the condition."

Check your policy to determine whether the carrier publishes any frequency guidelines. If, for example, the payer only allows you to use whirlpool once a week per patient, it will deny your claims if you exceed that frequency. This may be the reason for your denials.

If you believe that you have not exceeded frequency limits, you should send a letter to your carrier explaining that you performed wound care, along with a copy of the payer's policy. Underline or highlight the section that has the exception for wound care, and ask the carrier to reconsider your claims.