TRAINING OPTIONS:
Attend Feb. 12-13, 2010 class - Water-Based Intervention for the Geriatric Client: An Aquatic Therapy Primer
Attend Oct. 8-19, 2010 class - Novel Aquatic Balance, Proprioception and Fall Prevention Strategies
Attend Oct. 8-19, 2010 class - Novel Aquatic Balance, Proprioception and Fall Prevention Strategies
This is Part 3 of a multi-part series.
Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. These physicians are contracted to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.
Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. In the past two postings on this issue, the reviewer found that aquatic therapy was necessary.
In this posting, the reviewer found that aquatic therapy was as effective as land-based therapy... but that this should lead to its denial. These findings seem capricious and ill-informed -- the reviewer state b/c there is no literature which supports the effectiveness of aquatic therapy as better than land-based therapy, that aquatic therapy should not be considered a reimbursable service. What a strange thought.
First of all, the foundational contention is wrong. There have been dozens of studies in the last 10 years which have shown that aquatic therapy offers an advantage over land-based therapy for pain and many other facets of treatment.
Second, if 2 treatment choices are equally effective -- but both are effective -- why deny one as medically unnecessary?
Read these decisions for yourself.Findings: The physician reviewer found that although aquatic therapy is certainly a choice of modality for treatment, there is no proven benefit over land-based PT in the treatment of osteoarthritis of the knee/hip. The study by Wyatt and colleagues found that both aquatic and land-based exercise programs were beneficial for osteoarthritis. Bartels and colleagues review of several studies for aquatic exercise for knee and hip osteoarthritis determined that the available studies were not conclusive to recommend aquatic therapy over land-based therapy. This reviewer did not find any published randomized, controlled trials comparing the effects of land-based versus aquatic PT for patients following TKA. Ulrich and colleagues study regarding focused rehabilitation treatment of poorly functioning TKA recommends various rehabilitation techniques, but they do not include aquatic therapy. Based on the totality of the available evidence, aquatic therapy following TKA has no proven benefit over land-based PT. Here, although this patient had improvement in ROM, aquatic therapy is not proven to be superior to traditional (i.e., land-based) physical therapy. The gains may have been made had the patient continued land-based therapy.
The Case: The patient is a 48-year-old female with degenerative disc disease and myofascial neck pain. She has been receiving physical therapy (PT) and it has apparently been helpful. The patient's provider prescribed continued physical therapy and aquatic evaluation and therapy. The patient's request for authorization of continued physical therapy and aquatic evaluation and therapy was denied by the Health Plan based on a determination that the therapies are not medically necessary.
Findings: A review of the record shows that the patient was receiving physical therapy and that it was beneficial. Some instruction in a home exercise program was provided, but the PT progress notes indicate the patient had not been fully instructed. Since land-based physical therapy was helpful to the patient, aquatic therapy would not be medically necessary at this time. The patient should continue with the land-based physical therapy in order to complete all of the instruction necessary for a home-based exercise program. Three times per week for three weeks would be a reasonable time frame. Based upon the information set forth above, I have determined one of the requested therapies is medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.
The Case: A 45-year-old female enrollee requested authorization and coverage of
continued speech therapy, cognitive therapy, physical therapy, and
aquatic therapy. The Health Plan denied the request indicating that the
requested therapies are not medically necessary for treatment of the
enrollee's traumatic brain injury.
Findings: One physician reviewer performed a
medical necessity Independent Medical Review. The physician reviewer
partially overturned the Health Plan's denial on the basis that the
requested physical therapy is medically necessary but speech therapy,
cognitive therapy, and aquatic therapy in excess of the therapy already
approved by the Health Plan is not medically necessary.
Attend 2010 seminar - Aquatic Therapy Training Options for the Collegiate, Professional and Elite Athlete
Bridey-Lee Momberg, Quinette Louw, Lynette Crous. Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction:a series of three single subject case studies. SAJSM. 2008; 20(4): 109-114.
DOWNLOAD FULL TEXT (PDF)
Objective. To investigate the effectiveness of accelerated rehabilitation and accelerated hydrotherapy after anterior cruciate ligament (ACL) reconstruction in male athletes participating in soccer.
Design. A non-concurrent single subject, multiple baseline design (ABA design) was conducted over 10 weeks. A series of three N=1 studies was conducted to assess the effect of an accelerated hydrotherapy programme on pain, function, and range of motion.
Setting. The study was conducted at a private physiotherapy practice in Port Elizabeth, South Africa.
Interventions. The land rehabilitation programme was a homebased programme supervised every week by the physiotherapist. The accelerated hydrotherapy consisted of a 6-week programme, and participants attended two treatment sessions of accelerated hydrotherapy per week each of 30 minutes' duration.
Main outcome measures. The knee injury and osteoarthritis outcome scale (KOOS) as a subjective measure of pain, function and quality of life; the goniometer to measure active knee ROM and the 6-minute walking test (6MWT) as an objective measure of function.
Results. All three patients demonstrated good improvement during the treatment phase for the KOOS scale and progressed well
CORESPONDENCE:
Professor Quinette Louw
Division of Physiotherapy
Department of Interdisciplinary Health Sciences
Faculty of Health Sciences
Stellenbosch University
PO Box 19063
Tygerberg 7505
Republic of South Africa
Tel: +27(021) 938 - 9301
Fax: +27(021) 931-1252
E-mail: qalouw@sun.ac.za
Bridey-Lee Momberg (BSc, MSc Physiotherapy (OMT))
Quinette Louw (BSc, MASP, PhD)
Lynette Crous (BSc, MSc)
Division of Physiotherapy, University of Stellenbosch
Sato D, Kaneda K, Wakabayashi H, Nomura T. Comparison
of 2-year effects of once and twice weekly water exercise on activities
of daily living ability of community dwelling frail elderly. Arch Gerontol Geriatr. 2009 Jul-Aug;49(1):123-8.
This study aims at comparing the effects of once- and twice-weekly water exercise on the ADL ability of frail elderly receiving nursing care for 2 years. The design is a prospective randomized longitudinal study. Participants were assigned to two different exercise groups (Group 1 and Group 2). Group 1 participated in a 60-min exercise session once a week, for 2 years, while Group 2 attended the session twice a week.
Exercise sessions were divided into a 10-min warm-up on land and 50 min of exercise in water. The 50-min water exercise program consisted of 20 min walking, 10 min ADL exercise, 10 min stretching and strength exercises, and 10 min relaxation in water.
ADL ability and lower muscle strength were measured before the beginning of exercise and 6 months, 1 year, and 2 years after the program had started.
Significant group differences occurred for bathing transfer and stair climbing at the 2-year measurement. These results suggested that at least twice-weekly water exercise was necessary to maintain the ADL ability and KEX of the frail elderly during the 1-year water exercise period and for one additional year afterward.
Water-Based Intervention for the Musculoskeletal Client:
An Aquatic Therapy Primer
Taught By: Andrea Salzman, MS, PT
January 15-16, 2010
Minneapolis, MN
$595
Get details on this course -- and 18 other aquatic therapy classes held in 2010 -- at Aquatic Therapy University or www.aquatic-university.com
PREREQUISITES
A 4-hr ATU Bootcamp is offered at no additional cost immediately prior to this class (see next column for schedule). This class is required before taking any ATU course (current water-gurus excepted).
A 18 hr. training module packed into 2 days (4 hr. Boot Camp plus 14 hr. main course). Designed to rapidly introduce clinicians to basic treatment ideas for the musculoskeletal patient. Will provide an overview of treatments pertinent to pediatric, adult and geriatric practices. Includes a “sampler lab” of the most clinically useful elements of popular aquatic specialty techniques and research findings which support aquatic therapy. Provides an introduction to the following techniques: Watsu®, the Bad Ragaz Ring Method, Ai Chi, Task Type Training Approach, the Aquatic Berg (for balance), Aquatic Sensory Integration (ASI) and drills loosely based on the Halliwick Method.
LEARNING OBJECTIVES
8. Working with a partner, design and implement a 15-minute aquatic treatment plan (including equipment selection) for 1-2 of the following:
Dry hydrotherapy, also referred to as aquamassage, water massage or hydromassage, is a treatment that incorporates water with the intent of providing therapeutic massage.
Is it therapeutic? Maybe...
Is it reimbursable? Not according to several insurance companies.
Just to name a few, these payers now find DH experimental or investigational.
Why one company says your practice should include dry hydrotherapy anyway.
In dry hydrotherapy, the water is contained in a bed or chair, and the patient is separated from the water by a waterproof barrier, such as a vinyl cover. The user remains fully clothed and dry during the treatment. Pumps or water jets circulate, pulsate and spray the water within the contained area. Streams of pulsating water are sent along the patient’s body as the individual sits or lies on the device. The treatment is generally provided in chiropractor or physical therapy offices.
Independent medical review is the process where physicians
review medical cases in order to provide claims determinations for
health insurance payers, workers compensation insurance payers or
disability insurance payers. These
physicians are contracted to provide objective, unbiased
determinations on what the root cause of the treatment was, whether or
not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.
Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. Their findings might help you support your own treatment choices.
This is Part 2 of a multi-part series.
The Case: The patient is a 54-year-old female with a history of fibromyalgia and
pain in her neck, right hip, feet, knees, hands and wrists. The patient has
requested reimbursement for the aquatic therapy provided in February
2005 and prospective authorization for additional aquatic therapy. The
Health Plan has denied these requests based upon a determination that
the therapy was/is not medically necessary.
Findings: Although the patient has a chronic condition, she had not had much relief with traditional land-based physical therapy alone. A trial of aquatic therapy was reasonable and consistent with Medicare guidelines and standards within the medical community. The aquatic therapy provided in February 2005 was medically necessary and should have also included a component of patient education. Authorization for ongoing aquatic therapy is not medically necessary, as the patient should have been provided with the instruction necessary to continue her aquatic exercise program independently. Based upon the information set forth above, I have determined that although additional aquatic therapy is not medically necessary for treatment of the patient's medical condition, the therapy provided in February 2005 was medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.
Just a reminder of a change that happened in Medicare policy last summer...
According to the CMS:
When therapy services may be furnished appropriately in a community pool by a clinician in a PT or OT private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider shall rent or lease the pool, or a specific portion of the pool. [Emphasis added]
The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider. The written agreement to rent or lease the pool shall be available for review on request. When part of the pool is rented or leased, the agreement shall describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies.
Other providers, including providers of outpatient physical therapy and speech-language pathology (OPTs or rehabilitation agencies) and CORFs, are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools.
Medicare Benefit Policy Manual- Chapter 15 – Covered Medical and Other Health Services (See Section 220C) (Revision 109, 08-07-09)
Independent medical review is the process where physicians
review medical cases in order to provide claims determinations for
health insurance payers, workers compensation insurance payers or
disability insurance payers. These
physicians are contracted to provide objective, unbiased
determinations on what the root cause of the treatment was, whether or
not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.
Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. Their findings might help you support your own treatment choices.
This is Part 1 of a multi-part series.
Findings: The physician reviewer found that the rehabilitative management of patients following total joint arthroplasty should be individualized and geared toward the specific functional needs of a given patient. A recent randomized controlled trial by Rahmann and colleagues has demonstrated the beneficial effects of aquatic physiotherapy following total joint arthroplasty.
In this patient's case, there is a significant pain component that could limit functional recovery. It is therefore likely that the patient will better tolerate and progress with an aquatics-based program as opposed to a land-based therapeutic exercise program. The requested services are medically appropriate and likely to result in an improved outcome for this patient as compared to land-based therapy.
Here are some links to the latest facts about swim
diaper effectiveness. At their best, they still allow up to 2% fecal
matter to escape.
The takeaway? Nothing is poop-proof.
Inquiring minds want to know:
Answers to these questions -- straight from CMS (click here for master document). Here are a few of the highlights. (From 2006; published Feb 1, 2008)
[Editor's note: Looking for more recent statistics? You can order the 2008 data from Medicare for $100. Download the BESS file here. Contains private practice data only.]
How big a percentage of Medicare Part B claims does “aquatic therapy” (97113) represent?
In 2006, aquatic therapy comprised approximately .9% of claims. It was the 14th most frequently billed outpatient code behind:
97110 (therapeutic exercise) 33.03%
97140 (manual therapy) 11.37%
97530 (therapeutic activities) 9.52%
97112 (neuromuscular reeducation) 7.51%
G0283 (electrical stimulation - not wound care) 6.23%
97116 (gait training) 6.01%
97035 (ultrasound) 5.82%
97001 (PT eval) 3.09%
97535 (self care management) 2.95%
97032 (electric stimulation) 2.23%
97526 (treatment of swallowing dysfunction) 1.70%
97150 (group therapy) 1.33%
97124
(massage) 1.23%
Which settings are the most likely to bill for aquatic therapy?
Obviously, therapists/physicians are more likely to use the procedure “aquatic therapy” in a hospital, outpatient rehab facility. or outpatient PT setting than in a SNF or home health setting. So, although the code 97113 represented less than 1% of all claims to Medicare Part B in 2006, it represented over 2% of all claims made by hospitals. More here
How much were providers reimbursed for aquatic therapy?
Although “aquatic therapy” represented less than 1% of all claims
to Medicare B, it was responsible for 1.75% of all dollars reimbursed overall and over 2.3% of payments doled out to private practice PTs. Why? CPT code 97113 has a higher relative value (and thus
a higher reimbursement rate) than many of the other codes on the list. More here
How frequently do private practice PTs bill for aquatic therapy? How about private practice OT?
In
2006, private practice PTs were over 3x more likely to bill for
“aquatic therapy” than private practice OTs. More here
Often, when we share information about treating Medicare patients in the pool, we hear "Where does it say that in writing?"
Well, here it is from the horse's mouth. And this document includes information about all kinds of billing snafus -- not just group billing. (Note: Although it was created in 2002, it was reviewed 9/2009).
A little sample from the 11-pg CMS billing tip-sheet...
Supervision: The services of a therapist or therapy assistant cannot be billed for supervising a patient who is independently performing a therapeutic exercise program. Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service. See reference numbers 1. and 3. above.Use of Aides: You cannot bill Medicare for the services of an aide that is supervised by the therapist or therapy assistant. Medicare Part B does not pay for the services provided by aides regardless of the level of supervision. Medicare pays only for skilled, medically necessary services delivered
Team Therapy: Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units.
Group Therapy (sample scenario): In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C receives 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (97110) corresponding to the time of the skilled intervention with each patient.
To download the document, click here...
Faculty of Regional Environment Science, Tokyo University of Agriculture.
Background: The objective of this review was to summarize findings on aquatic exercise and balneotherapy and to assess the quality of systematic reviews based on randomized controlled trials.
Methods: Studies were eligible if they were systematic reviews based on randomized clinical trials (with or without a meta-analysis) that included at least 1 treatment group that received aquatic exercise or balneotherapy. We searched the following databases: Cochrane Database Systematic Review, MEDLINE, CINAHL, Web of Science, JDream II, and Ichushi-Web for articles published from the year 1990 to August 17, 2008.
Results: We found evidence that aquatic exercise had small but statistically significant effects on pain relief and related outcome measures of locomotor diseases (eg, arthritis, rheumatoid diseases, and low back pain). However, long-term effectiveness was unclear. Because evidence was lacking due to the poor methodological quality of balneotherapy studies, we were unable to make any conclusions on the effects of intervention. There were frequent flaws regarding the description of excluded RCTs and the assessment of publication bias in several trials. Two of the present authors independently assessed the quality of articles using the AMSTAR checklist.
Conclusions: Aquatic exercise had a small but statistically significant short-term effect on locomotor diseases. However, the effectiveness of balneotherapy in curing disease or improving health remains unclear.
DOWNLOAD THE | Abstract/Full Text | PDF
REFERENCE: Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil. 2009 Jan;23(1):3-14.
DOWNLOAD THE | Abstract | PDF |
REFERENCE: Carvalho VO, Bocchi EA, Guimarães GV. The Borg scale as an important tool of self-monitoring and self-regulation of exercise prescription in heart failure patients during hydrotherapy. A randomized blinded controlled trial. Circ J. 2009 Oct;73(10):1871-6. Epub 2009 Aug 28.
DOWNLOAD THE | Abstract/Full Text | PDF–699K |
REFERENCE: Benefit of warm water immersion on biventricular function in patients with chronic heart failure. Bente Grüner Sveälv, Åsa Cider, Margareta Scharin Täng, Eva Angwald, Dimitris Kardassis, and Bert Andersson. Cardiovasc Ultrasound. 2009; 7: 33. Published online 2009 July 6. doi: 10.1186/1476-7120-7-33.
Nearly 5000 aquatic therapists get it every week. So why not you?
Here are just a few of the topics you missed...
Click here to read all the archives... or to sign up to get the hotsheet emailed directly to you every Monday.
As with all Medicare services, aquatic therapy must be medically reasonable and necessary in order for the provider to receive payment. Here are some of the most common reasons intermediares such as Cigna are choosing to deny aquatic therapy.
Source: Cigna Government Services: Aquatic Therapy
(Editor's Note: I would argue that the first reason is absurd. As long as equivalent or better results have been shown for working in water (and the research is mounting!), there should be no reason to have to forgo the pool for land. If the argument is that working in an "aquatic environment" is not functional, then I'd like to see the payer explain why they willingly reimburse for spinal traction or unweighted treadmill work).
More good news for therapists who choose to take their s/p Total Knee Arthroplasty patients into the water. Water-based rehab works just as good as land... so it should be up to the therapist and patient to decide. What is it the insurance companies say? That the research isn't there to
support it. Or that the research that is there is weak and inconclusive. Well, this study scores an 8/10 on the PEDro scale. That's as good as it gets in the PM&R world.
OBJECTIVE: To compare outcomes between land-based and water-based exercise programs delivered in the early subacute phase up to 6 months after total knee replacement (TKR). METHODS: Two weeks after surgery (baseline), 102 patients were randomized to participate in either land-based (n = 49) or water-based (n = 53) exercise classes. Treatment parameters were guided by current clinical practice protocols. Therefore, each study arm involved 1-hour sessions twice a week for 6 weeks, with patient-determined exercise intensity. Session attendance was recorded. Outcomes were measured at baseline and at 8 and 26 weeks postsurgery. Outcomes included distance on the 6-Minute Walk test, stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (n = 85 English-proficient patients), visual analog scale for joint pain, passive knee range of motion, and knee edema (circumference). Planned orthogonal contrasts, with an intent-to-treat approach, were used to analyze the effects of time and time-group interactions. RESULTS: Compliance in both groups was excellent with 81% attending 8 or more sessions. Loss to followup was 5%. Significant improvements were observed across time in all outcomes at 8 weeks, with further improvements evident in all variables (except WOMAC pain) at 26 weeks. Minor between-group differences were evident for 4 outcomes (SCP, WOMAC stiffness, WOMAC function, and edema) but these appear clinically insignificant. CONCLUSION: A short-term, clinically pragmatic program of either land-based or water-based rehabilitation delivered in the early phase after TKR was associated with comparable outcomes at the end of the program and up to 26 weeks postsurgery. |
Yes, human-to-human transmission of H1N1 virus can occur. Even at your pool.
Transmission is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus.
From the NSPF: What actions should pool operators take at their aquatic facility?
Check out this 15 page Aquatic Exercise for MS download (tab down to the 4th publication on the page). It is part of a series of publications designed to help you help your patients with MS.
MS Practice is an initiative of MS Australia and is a series designed to support allied health professionals in the symptom management of people with multiple sclerosis (MS).
There are 7 fabulous downloads (including aquatics, balance, pain, strengthening, etc)
Looking for an aquatic rehab progression s/p THR? Read the following Total Hip Replacement protocol suggested by HydroWorx.
(Of course, protocols should never be followed blindly. They should be seen as a starting point for clinical decision making. Still, nice to have a starting point for discussion.)
In the mood for a freebie or 2? Attend the following seminars online for free courtesy the National Swimming Pool Foundation!
Health Benefit Track
Cardiorespiratory Fitness and Coronary Heart Disease Risk Factors in Women and Men Swimmers ~ Steven N. Blair, P.E.D., University of South Carolina (view abstract & bio) |
|
| Exercising the Mind: How Water-Based Exercise Can Improve Mental Health ~ John "Jack" S. Raglin, Ph.D., Indiana University (view abstract & bio) |
|
Aquatic Exercise for Better Functional Activities on Land ~ Mary E. Sanders, Ph.D., FACSM, University of Nevada – Reno/WaterFit (view abstract & bio) |
|
A Comparison of Water and Land Therapy Versus Land Therapy on the Outcome of Total Knee Arthroplasty ~ Richard McAvoy, PT, DPT, CSCS, Rehab 3 at Marshbrook (view abstract & bio) |
|
Cool, Warm, and Hot Water Immersion Effects on Cardiac and Circulatory Function ~ Bruce Becker, M.D., M.S.; Kasee Hildenbrand, Ph.D., Washington State University (view abstract & bio) |