CPT Code 97113 : Aquatic Therapy

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Introduction                                                                                      

Aquatic therapy is becoming an increasingly popular treatment option for individuals who are recovering from injury or managing chronic conditions. When it comes to billing for these services, understanding the appropriate CPT (Current Procedural Terminology) code is essential. One such code that often comes into play is CPT Code 97113. But what exactly does it cover, and why is it so important for aquatic therapy? In this article, we’ll explore everything you need to know about CPT Code 97113, its role in aquatic therapy, and how it affects billing and insurance coverage.

Key Takeaways

• CPT Code 97113 is used for aquatic therapy with therapeutic exercises.
• Proper documentation and medical necessity are crucial for reimbursement.
• Modifiers like 59 and GP should be applied when appropriate.
• Insurance prior authorization may be required.
• Aquatic therapy benefits orthopedic, neurological, pediatric, and geriatric patients.
• Avoid common billing errors to maximize reimbursement and minimize denials.

What is Aquatic Therapy?

Aquatic therapy involves the use of water-based exercises and treatments to help patients recover from injuries, surgery, or manage chronic pain and conditions. The buoyancy of water supports the body, reducing stress on joints and muscles, making it an ideal therapy for people with mobility limitations.

What is CPT Code 97113?

CPT 97113 refers to Aquatic Therapy with Therapeutic Exercises, performed in a water environment to facilitate movement and improve patient function. This therapy is particularly beneficial for individuals with arthritis, chronic pain, post-surgical recovery, and neurological disorders.

According to the American Medical Association (AMA), this code should be used when at least one of the following is performed:

• Strength training using water resistance
• Balance exercises to improve stability
• Flexibility training to enhance range of motion
• Functional training to support daily activities

When is CPT Code 97113 Used in Aquatic therapy?

Specific Scenarios for Usage

CPT Code 97113 is typically used when a therapist administers water-based therapeutic exercises, such as resistance training, stretching, and strengthening exercises, in a structured, one-on-one setting. This code is appropriate when water’s buoyancy and resistance are integral to the therapy being provided.

Who Can Bill CPT Code 97113?

Only licensed healthcare providers, such as physical therapists or occupational therapists, who are trained in Aquatic therapy can bill for services under CPT Code 97113. The code applies to one-on-one sessions, where a therapist works directly with the patient in a therapeutic pool or other water-based environment.

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Billing Guidelines for CPT 97113

Accurate medical billing is crucial to prevent claim denials and ensure timely reimbursement. Here are the top billing requirements for CPT 97113:

1. Medical Necessity: The therapy must be deemed medically necessary by the prescribing physician and well-documented in the patient’s records.
2. Documentation Requirements: Therapists should record:

•  Diagnosis and patient history
•  Specific goals of aquatic therapy
•  Exercises performed and patient progress
• Duration of therapy session

3. Use of Modifiers:

• Modifier 59: If the therapy is performed alongside other treatments to indicate a distinct service.
• GP Modifier: When services are performed under a physical therapy plan.

4. Insurance Preauthorization: Some insurance providers may require prior authorization for aquatic therapy to approve reimbursement.

Reimbursement and Insurance Coverage for CPT 97113

Many insurance plans, including Medicare and private insurers, provide reimbursement for CPT code 97113. However, reimbursement rates may vary based on:

• State regulations
• Insurance provider policies
• Medical necessity and documentation quality

Does Insurance Cover CPT 97113?

Not all insurance plans cover aquatic therapy, and some may only reimburse it if a specific medical condition or treatment plan is identified. It’s essential to confirm with the insurance provider that aquatic therapy is covered, and that CPT Code 97113 is recognized.

How to Maximize Reimbursement:

• Ensure detailed and accurate documentation
• Submit claims with correct modifiers
• Follow Medicare and private insurance billing guidelines
• Appeal denied claims with strong supporting documentation

Clinical Applications of Aquatic Therapy (CPT 97113)

Aquatic therapy is widely used for rehabilitation and pain management. It is especially beneficial for:

1. Orthopedic Rehabilitation

• Post-surgical recovery (e.g., knee and hip replacements)
• Chronic back pain and spinal disorders

2. Neurological Conditions

• Stroke recovery
• Multiple sclerosis (MS) and Parkinson’s disease

3. Pediatric Therapy

• Children with cerebral palsy and developmental disorders
• Sensory integration therapy

4. Geriatric Patients

• Osteoarthritis and joint pain
• Fall prevention and balance training

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Common CPT 97113 Billing Mistakes (and How to Avoid Them):

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Lack of Medical Necessity Documentation:

• Mistake: Failing to clearly document why aquatic therapy is medically necessary for the patient's specific condition and how it will improve their functional abilities.
• Solution: Document the patient's diagnosis, functional limitations, and why aquatic therapy is the most effective treatment option. Explain how it will address their specific needs and contribute to their overall treatment plan.

Incorrect Coding:

• Mistake: Using the wrong CPT code. For instance, using 97110 (Therapeutic Exercise) when the primary intervention is aquatic exercise, or using 97112 (Neuromuscular Re-education) when the focus is on strengthening and functional activities in the water.
• Solution: Ensure accurate coding by selecting the code that specifically reflects the skilled interventions provided. If the therapy primarily involves aquatic exercises, 97113 is likely the correct code.

Insufficient Time Documentation:

• Mistake: Inaccurately documenting the time spent providing direct, one-on-one patient care during aquatic therapy sessions. Including time spent on documentation, patient setup, or other tasks outside of direct patient care.
• Solution: Accurately track and record the time spent providing skilled interventions in the water with the patient. 97113 is a time-based code, and proper documentation of time is essential for reimbursement.

Incorrect Modifier Usage:

• Mistake: Using incorrect or omitting necessary modifiers.
• Solution: Use the appropriate modifiers to provide additional information about the service. For example:
• Modifier 59: Use this modifier to indicate a distinct service when 97113 is performed separately from other procedures during the same session. (Example: If you perform land-based therapy and then aquatic therapy, you might use 59 on the second service if they are truly separate and distinct).
• GP Modifier: Use this modifier when services are provided under a physical therapy plan of care.

Unbundling:

• Mistake: Billing separately for services that are included in the 97113 code. For example, billing separately for gait training or manual therapy that is performed within the aquatic therapy session and is part of the overall therapeutic exercise.
• Solution: Avoid unbundling by understanding what is included in 97113. If gait training or other interventions are part of the aquatic exercise session, they should not be billed separately.

Conclusion

CPT code 97113 plays a vital role in aquatic therapy billing and ensures accurate reimbursement for healthcare providers. By following proper billing guidelines, documentation requirements, and insurance policies, clinics can enhance their revenue cycle management while providing effective therapy to patients.

For healthcare providers looking to improve billing efficiency, staying informed about reimbursement trends and coding updates is essential. If you need help navigating aquatic therapy billing, consult with medical billing experts or use practice management software to streamline the process.

FAQs

What Is the Cost of Aquatic Therapy with CPT Code 97113?

Costs vary depending on location, insurance coverage, and the therapist’s fees. It’s essential to confirm with the provider and insurance company beforehand.

Does Medicare cover CPT code 97113?

Yes, Medicare covers CPT 97113 under specific conditions, provided that the therapy is medically necessary and meets documentation requirements.

How often can CPT 97113 be billed?

CPT 97113 is billed per 15-minute session and must include one-on-one patient contact with the therapist.

What are the most common denials for CPT 97113?

The most frequent reasons for denial include lack of medical necessity, missing modifiers, and insufficient documentation.

Can CPT 97113 be billed with other therapy codes?

Yes, it can be billed alongside other therapy codes, but appropriate modifiers should be used to distinguish services.

What is the average reimbursement for CPT 97113?

Reimbursement rates vary by state and insurance provider, but they typically range from $30 to $50 per 15-minute session.

How Do I Find a Qualified Aquatic Therapist?

Look for licensed physical or occupational therapists with certifications in Aquatic therapy, such as those offered by ATRI.

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