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Should you be in the Pool with your Patient?

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Today you receive a request from your Medicare contractor asking for verification that during each aquatic therapy session, the therapist was in the water.

This request would be a concern for many reasons, not all having to do with whether the therapist got wet. Think about it. How many of your charts make notation of the location of the therapist during the aquatic session.

Should they? Is this even a valid restriction or reason for denial? Does the therapist have to be in the water for it to be considered skilled care?

While this decision is ultimately between you and your Medicare contractor, let's tease out the two issues being discussed here.

Skilled Vs. Unskilled Care

First, is it "skilled" care for the therapist to remain on the deck? 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, to alter the current speed rapidly and to assess the running pattern of the injured athlete. 

    • 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 replacement. 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 jump 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, shouldn't the therapist be in a bathing suit, prepared to get in?

Billable Vs. Non-Billable Care

So, let's put aside the question of skill. Let's assume that the care you are providing is skilled. You are confident that there is a reason for you to be in the pool when you are in... and an equally compelling reason to be out when you are out. In both environments, you are serving a proper 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.

Local Coverage Determinations

Here are several examples of the language you will find memorialized in LCDs from different Medicare contractors. These policies address this very issue is easy to decipher language.

CONTRACTOR: Wisconsin Physicians Service Insurance Corp.

Excerpt of: CPT Code 97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises:

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 services.

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.

Excerpt from: CPT 97113 - Aquatic therapy/exercises

The qualified professional/personnel auxiliary personnel does not need to be in the water with the patient unless there is an identified safety issue.

Source: http://apps.ngsmedicare.com/lcd/LCD_L26884.htm

CONTRACTOR: Highmark Medicare Services Inc.

Excerpt from: 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.

Source: https://www.novitas-solutions.com/policy/mac-ab/l27513-r10.html

"CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association."

Conclusion

If your local contractor is requiring you to show that therapists are in the water during patient care, ask to see the LCD or written policy that states this coverage decision. I would argue that it is unfair for a payer to deny care when their own written policies do not discuss any such requirements.

That said, even if you are permitted to remain on the deck, that 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, then you may need to ask yourself some stirring questions about the quality -- and skilled nature -- of your care.

Disagree? Great. I'm wrong all the time. Let's hear you make your best case for providing skilled care on the deck!

Andrea Salzman is creator of the Aquatic Resources Network (www.aquaticnet.com), an online clearinghouse of aquatic therapy and fitness information. 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 (www.swimatu.com). Contact Andrea at asalzman@aquaticnet.com.


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