Quantification and Qualification Keys in Calming Rocky Reimbursement Waters of

Aquatic PT

By Tracy Feeney

'It used to be a lot easier to practice aquatic physical therapy," recalled Robert Babb, PT, vice president and director of rehabilitation at the Philadelphia Center for Aquatic Rehabilitation in Philadelphia, of the days when therapists were able to spend the majority of their time in the water working one on one with their patients.

Today, many therapists would agree that they spend much more time juggling interactions with the rehabilitation nurse, physician, case manager, adjuster and managed care company when administering effective, and perhaps equally important, reimbursable aquatic PT.

Because there are so many factors involved in the current health care system and therapists' provision of care isn't solely focused on the patient, an urgent need arises to concentrate on refocusing and economizing care so that patients don't get lost in what seems to be a tidal wave of change.

"If I had to identify what the biggest change has been given the impact of managed care on aquatic physical therapy, I'd say that the cost on therapists administratively has quadrupled over the past five years," he indicated. "And, this shift really affects how much time we have available to actually work with patients in the water."

FOR EXAMPLE, prior to managed care changes, Babb indicated that the therapists at PCAR would perform an initial evaluation on their patients in one hour. Now, factoring in the amount of time required for paperwork and documentation, therapists are given an hour and 15 minutes to complete the task.

"Changes are always being made that require therapists to stay focused on time management skills," he added, commenting that one successful strategy implemented by his staff is to set aside specific blocks of time for communication between interdisciplinary team members.

"Keeping communication open with the physician has always been a big priority for us," said Babb. "In fact, we have one PTA on staff whose main ancillary responsibility is initiating daily phone calls to physicians between 2 and 4 p.m."

Aside from streamlining communication as a way to ensure that everyone is on the same page when it comes to a particular patient, accurate documentation is essential if therapists expect to be reimbursed for the services.

Today, documentation and outcomes measures are buzzwords that go hand in hand. Tracking patients from the time they come into the clinic until the time they leave is essential, noted Babb. "Recently, we heard that AETNA has been trying to drop the APT code and deny forms of aquatic reimbursement claiming that in their research reviews, they found there was a lack of scientific information supporting the efficacy of aquatic physical therapy.

"IN THE PAST few years, I've often heard people say that there was nothing in the literature that said therapists should utilize aquatic PT intervention to help their patient, but that just isn't true," indicated Andrea Poteat, MS, PT, manager of therapeutic aquatics at St. Paul Ramsey Medical Center, St. Paul, MN, and owner of Concepts in Physical Therapy, a consulting business located in White Bear, MN.

Poteat recently compiled a 50-page annotated bibliography citing research studies examining the effectiveness and efficiency of aquatic intervention. "At first I was just putting together one page summaries for myself," she stated. "And then I began to realize that there is really a lot of peer reviewed aquatic therapy literature out there, especially in the cardiopulmonary realm."

After going back to the articles she had summarized, Poteat added statistical information that would allow others to read it as a scientific study. Now, she often submits the information along with a progress note regarding a particular patient to physicians and insurance companies in an effort to gain a collective understanding of the patient's needs.

In general, therapists are charged with the responsibility of backing up the use of aquatic PT when treating patients by providing payers with current clinical evidence and outcomes data.

Poteat identified two methods of quantifying patients' functional changes as performance measures and self-report surveys. After initially testing the patient using either of these tools, appropriate aquatic physical therapy intervention is performed and then patients are retested to determine whether they have progressed on the scales.

"Subjectively, patients can say that they have experienced an improvement in their balance, but with self-reports and performance measures we have the objective evidence to show it," stated Poteat, indicating that her staff has been collecting patient outcomes and putting them into a data base for more than two years.

"BECAUSE WE have these tools, we can catch it a lot earlier when certain therapeutic interventions aren't helping the patient," she stressed. "I realize that I'm just one option in the repertoire, and I am the first person to look the patient in the face and say, 'I don't think this intervention is helping you.' Really, we are in an ideal situation as aquatic physical therapists: We are physical therapist with the knowledge and the ability to harness air and water to meet the needs of our patients. We are not limited to one environment."

"We fill out Oswestry forms on a monthly basis to get an idea of how patients are improving functionally," echoed Babb, noting that at the end of every year, the forms are compiled by a representative from Hahnemann University in Philadelphia.

Information including how many patients were seen in the year, how long each patient's stay was and patients' average age are used to determine the cost effectiveness of the facility. "We need to document to third party payers the outcomes for how successful we are as a facility and how successful we are with various treatment techniques."

Much of the opposition that Babb receives from third party payers is associated with expecting reimbursement for specialty treatment techniques such as dynamic stabilization exercises. "It's difficult for payers to understand that we are attempting to create a stable movement pattern that is not just an exercise, but an entirely new movement pattern to develop better functional end results for the patient," he stressed.

ULTIMATELY, the goal is to convince third party payers that specific techniques are not only essential but can be successful as well.

"We insist that a rehabilitation nurse come to the facility to see what we are doing and encourage them to get involved in the total rehab process," said Babb, adding that every Friday afternoon, rehabilitation nurses receive a letter from PCAR regarding the progress their patients are making at the facility.

Linking aquatic physical therapy activities with patients' daily skills, return to work status and other functional lifestyle indicators is a crucial aspect of documenting therapeutic outcomes. For this, Babb championed the effectiveness of equipping the clinic with a functional activity room.

"We actually use a functional activity trailer where patients are tested on 20 functional tasks and graded from zero to five to indicate specifically how they are functioning in everyday life," he noted, explaining that simulators are used to test patients on how well they can do laundry, reach in the office or kitchen, or even opening the garage door.

"NOW, INSTEAD of asking patients to quantify functional skills themselves, we give third party payers a quantifiable sheet listing their scores so that they can see the actual progress on paper," he stressed.

According to Babb, it is also important to prove to managed care companies that there is a land-based component in every aquatic physical therapy program. "The land-based component is a necessity with the exception of patients with chronic long-term ailments such as post-polio syndrome where they've already reached a maximum of success and we know that they won't be able to progress much further. For these patients, an aquatic exercise program is going to be their need, he said.

Another obstacle to be overcome on the reimbursement front is combatting the notion among third party payers that overutilization and overcharging are common occurrences in aquatic PT.

"I think progression is one safeguard that we have to hopefully correct this misconception," he said, encouraging therapists to schedule patient care meetings frequently to look at patients' progress. "We need to sit down and challenge ourselves and each other and ask, 'Is this patient making progress?'"

That's why good communication is paramount, indicated Babb, noting that PCAR participates in a utilization review meeting once every other month with a physiatrist from Moss Rehabilitation Hospital in Philadelphia to trouble shoot and discuss methods of streamlining progress.

POTEAT OFFERED another suggestion to avoid any payer misconceptions regarding overutilization. She recommended that therapists use a pro-active approach with payers. She claimed that this technique can make a big difference in the way that insurance companies view clinics.

For example, she noted that a patient with arthritis may be approved for 10 visits of aquatic physical therapy; however, if the therapist feels that the patient has already concentrated on the issues specific to their needs in only three visits, they may want to progress them to a group class. "Do it when you should and you gain the payer's respect to not have to do it when you shouldn't. You have done your own utilization review and made this hard decision yourself."

The problem, she stressed, is that once a plan of care is determined, the insurance company won't often foot the bill for what the therapist feels is an appropriate therapeutic change.

"Ideally, third party payers should allow the medical professionals to make decisions regarding the course of patient care and when that care should be terminated," she said. "But these days it seems as though it's the insurance companies that have taken to practicing medicine without a license."

ACCORDING TO Poteat, it's the patient that ends up losing in this situation when they become reinjured and are referred to physical therapy again three months down the road. Babb agreed, this situation is one that therapists as well as third party payers should strive to avoid.

"One of our main objectives is getting third party payers to understand what we are doing and developing a good report that will benefit the patient," said Babb, noting that his facility has recently affiliated their aquatic physical therapy program with Moss Rehabilitation in Philadelphia. He added that this union has gained PCAR a certain amount of respect and a raised eye when people hear about the program.

So, for clinics still struggling to gain reimbursement dollars for aquatic services, Babb recommended garnering support from reputable physicians and hospitals. "This is an excellent way of acquiring more exposure for the services your clinic has available, as well as gaining the help that is needed to spread the word regarding the efficacy of aquatic physical therapy," he concluded. *