Denying Aquatic Therapy: The New Payer Past-time?

Providers need to be aware that payers see aquatic therapy as worthy of special attention.

In 1995, the American Medical Association (AMA) defined aquatic therapy as a new procedure code (CPT 97113) in order to differentiate it from whirlpool and other passive aquatic treatments. From the start, 97113 was a very different kind of code than all others. Why? Because it described an environment and not an intervention.

Think about it this way. When therapists perform gait training in the water, there is now no way to code that act differently from when they provide manual therapy-or therapeutic exercise or any other procedure-in the water. The payer knows where the action took place, but not "what kind" of action it was. This may be at the center of the problem that insurers are having with the 97113 code.

By making aquatic therapy its own special code, the AMA made it seem as if aquatic-based interventions are unique (insurers read this: experimental), instead of the same old procedures taking place in an aquatic medium.

Providers don't have a separate code or mat-based therapy or plinth-based therapy; why a separate code for pool-based therapy? It does not describe the intervention that is taking place, but only the medium in which it occurs.

That said, the problem is now difficult to correct. If the AMA rectified this situation by eliminating the aquatic therapy code and suggested that providers return to using other codes to bill for services, payers would see this as an indication that aquatic therapy is no longer a coverable service.

In many ways, insurers now consider aquatic therapy as a red-flag. Providers need to be aware that payers see aquatic therapy as a noteworthy code, worthy of special attention, and act accordingly.

Centers for Medicare and Medicaid Services (CMS)

Medicare and Medicaid are federal programs; however, CMS leaves many reimbursement decisions up to its local contractors (known as Fiscal Intermediaries and Medicare Administrative Contractors). This means that although aquatic therapy is considered a coverable service under federal rules, any local contractor may restrict its use or deny coverage unless certain standards are met.

These standards, known as LCDs (local coverage determinations), can vary wildly from state to state and contractor to contractor. Because many therapists are unaware of LCDs, they can get caught with their pants down (financially speaking) when billing for aquatic therapy.

There is a single "go to" source to find out exactly what each local Medicare contractor has to say about aquatic therapy in its LCDs. Here's a link which will help therapists find any LCDs which relate to their specific Medicare contractors:

Some Medicare contractors treat aquatic therapy as just another physical medicine code. However, this is by no means universal; other contractors are currently flagging aquatic therapy as a billed service worthy of special attention.

For instance, in 2007, Cigna reported that they found several concerns regarding the practice and documentation of aquatic therapy for Medicare patients. They published an article to alert providers to their concerns. Here are the reasons they cited for taking an extra look at CPT code 97113 (aquatic therapy).

·         Therapy services were provided to beneficiaries with no identified need for the use of this type of therapy. There was little evidence to support the need for use of a water based environment (i.e. buoyancy for un-weighting joints, resistance, and/or loss of motion).

·         Services were provided for excessive durations of time per treatment session. In some cases aquatic therapy was rendered in excess of one hour.

·         Aquatic therapy services continued for long periods of time (several months) in the absence of documented functional gains.

·         Services were repetitive in nature and appeared to be for conditioning and overall fitness or maintenance.

·         There was little evidence of transitioning the aquatic exercise program to a land-based exercise program to improve functional performance with every day activities.

·         The programs provided in the pool setting were rendered in a group environment yet individual therapy was billed.

Based on these findings, Cigna initiated several investigations and made aquatic therapy a major area in their strategic medical review plan.

Private Payers

Private payers tend to follow the broad path created by Medicare. However, not all payers treat aquatic therapy equally. Over a decade ago, one payer's national office made a controversial decision to deny all aquatic therapy as experimental in nature. This national decision was redacted before it was ever implemented, but the damage was done.

Since that time, this payer's national office has published a policy paper which states unequivocally that they consider aquatic therapy medically necessary for musculoskeletal conditions. To this day, in the eyes of many local branches, all aquatic therapy charges remain suspect.

Each payer has its own rules and regulations. For a sample of common standards applied to the "aquatic therapy" code, see the sidebar. Note that these standards go far beyond just establishing that the aquatic intervention was medically necessary.

Workers' Compensation

Aquatic therapy is a covered service under some employee's Worker's Compensation plans. For a master list of Worker's Compensation rules and statutes for each state, log onto:

Under certain circumstances, the WC insurer will question whether aquatic therapy was really medically necessary. If this occurs and the insurer then denies the charges, the issue often goes to an independent review board or a compensation judge. In many states, any review must include all the following factors:

·         The employee's unique disabilities and assets in relation to the goals, objectives, and timetable of the rehabilitation plan;

·         The type of rehabilitation services provided and the actual amount of time and expense incurred in providing the service;

·         An evaluation of whether services provided were unnecessary, duplicated other services, were available at no charge to public, or were excessive relative to the actual needs of the employee; and

·         An evaluation of whether services rendered were expressly called for by the employee's rehabilitation plan.

Sometimes independent reviews support the denial; other times, they rule against the insurer. As the literature supporting the effectiveness grows, the scales will tip towards allowing aquatic therapy as medically necessary in many situations.

For some reason, insurance companies have it in their respective heads that aquatic therapy requires extra special justification. Payers will often make the argument that rehab in water isn't functional. Why? Because people don't live in water. Well, people don't live on the receiving end of an ultrasound head either. Or draped over a treatment plinth. Or, for that matter, performing leg presses in a rehab gym. But somehow, those interventions are considered functional.

The result? Clinicians who work in the water have to make a special-some would argue Herculean-effort to support their treatment rationale. It's a bother, frankly, but one worth doing right. To avoid the most common pitfalls when billing under this code, see the sidebar article. and make the reimbursement process as painless as possible.

Common pitfalls in billing for aquatic therapy (97113)

Read these tips to make billing with the CPT code 97113 as painless as possible. Note: This reference cites one Medicare Contractor; there are hundreds of contractors, each with their own standards, however, these 5 standards crop up almost all the time.

CPT 97113, Aquatic therapy/exercises

1. Since this procedure uses the therapeutic properties of water (e.g., buoyancy, resistance), documentation must support the need for a water environment. 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, levels of assistance) and should demonstrate progression to land-based activities.

2. This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).

3. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy. This includes when the patient cannot perform land-based exercises effectively to treat his/her condition without first undergoing the aquatic therapy or when aquatic therapy facilitates progress to land-based exercise or increased function. There may be instances where land-based activities were attempted prior to the use of water-based activities. In these cases, the documentation shall provide evidence that the beneficiary was not progressing with land-based efforts and offer rationale for the use of water-based services (i.e., severe pain, inability to support body weight).

The continued use of aquatic therapy without any eventual progression to land-based activities would not be considered medically necessary. The transition from water based to land based is required to allow functional performance with every day activities and documentation must be available in the record to support medical necessity.

4. It is not medically necessary to have more than one form of hydrotherapy (codes 97022 and 97036) during the same visit.

5. The billing of aquatic therapy code (97113) is for one-on-one therapy provided in the pool. In the situation where services are provided to more than one beneficiary, the only permissible code to bill is group therapy (97150).

SOURCE: Code Map for Aquatic Therapy (97113).

Andrea Salzman is creator of the Aquatic Resources Network (, the single largest clearinghouse of aquatic therapy and fitness information online. At the ARN Online Command Center, more than 8,000 aquatic-specific articles and downloads are available free for the public. Individuals seeking advanced competency in aquatic therapy can now pursue a tiered curriculum of training through Aquatic Therapy University ( In 2010, Salzman teamed with 12 PTs/OTs/SLPs/MDs and PhDs to develop this first-in-the-industry Aquatic Therapy Credentialing Path, an 84-hour progression of training for the therapist seeking advanced clinical expertise. Drop Andrea a note at (She gets out of the pool at 5:00!) Copyright 2012. All rights reserved.

Water Wisdom Archives

A child I met who had been receiving water therapy is being denied it now under Katie Beckett Funds in Wis.. The family sees where the therapy has helped her with her ability to move. She lives at home and her parents are her primary caregivers.
What suggestions do you have in order to regain and keep funding for this type of funding?

Margaret StaussAugust 15, 2016
Menomonie, WI

I know that aquatic therapy will help with my pain ans soreness from arthritis, complications from scoliosis, degenerating disc, sciatica, and muscle spasm to list a few. However no doctor take Maryland Physician Care and they don't care to cover it.

Natalie October 07, 2015

I have degenerative arthritis that is ever worsening. I had a cervical fusion (3 level). I have broken hardware and a non-fusion. I cannot look up without pain, I am limited to looking down in short intervals. I've done PT on numerous occasions. My bones ache and need the pressure release in a non weight bearing medium. I have a policy with Cigna who denies this service request through my neurosurgeon. Any suggestions?

Carol BoxudreauxAugust 14, 2015
Gonzales, LA

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