Are you treating a patient who cannot perform conventional land-based therapy? In situations where patients experience joint stress while exercising, therapists opt for aquatic therapy for rehabilitation.
But, does Medicare consider it a medical service and reimburse it? Yes, Medicare does reimburse aquatic therapy, given that supporting documents were attached to prove the procedure’s medical necessity.
CPT code 97113 is the correct billing code for these services. However, medical billing is not that simple. Knowing the accurate code is not enough for correct billing. You must also be aware of the applicable modifiers and proper reimbursement guidelines. So, let’s get right into the details.
CPT Code 97113 – Description
CPT code 97113 describes a special therapeutic procedure where the provider instructs and supervises the patient on aquatic therapeutic exercises for one or more areas of the body for a period of 15 minutes.
Scenarios Where CPT Code 97113 is Applicable
The following are some scenarios where water therapy is provided and billed with code 97113.
Post-Surgical Rehabilitation
Suppose a 62-year-old patient experiences ongoing knee pain, edema, and trouble with full weight-bearing exercises on land four weeks after complete knee replacement. After analyzing his situation, the healthcare professional suggested that the land-based strengthening activities are not yet suitable for him due to restricted knee flexion and a fear of falling. So, a physiotherapist renders one-on-one aquatic therapy in a heated pool to the patient. He guides the patient through supported squats, knee flexion and extension exercises, and gait training.
As the therapist provided one-on-one therapy with guidance, he may bill CPT code 97113 for the reimbursement of his service.
Gait Training for a Stroke Patient
Now imagine a 58-year-old patient exhibits right-sided weakness, poor balance, and a fear of falling. During gait training on land, the patient needs the most assistance possible. To promote safer mobility, aquatic therapy is recommended. In waist-to-chest-deep water, the therapist offers one-on-one aquatic exercises, such as weight shifting, aided walking, and upper-extremity strengthening.
Before moving on to land-based therapy, the water environment helps with coordination and confidence by supporting balance and enabling repetitive functional movements. Since the physical therapist instructs and supervises the patient during aquatic therapy, he can bill CPT code 97113.
Applicable Modifiers for CPT Code 97113
The following are two modifiers often applied to CPT code 97113.
Modifier GP
If the services were rendered as part of an outpatient physical therapy plan of care, the GP modifier should be used with CPT code 97113. It also helps the payer acknowledge that aquatic therapeutic exercises were supervised by a licensed physical therapist.
Modifier 59
Modifier 59 may be used with CPT code 97113 if the paperwork clearly demonstrates that the procedure was different from other procedures performed on the same day.
CPT Code 97113 – Billing & Reimbursement Guidelines
The most important part of this read is the billing and reimbursement guidelines for CPT code 97113, which are as follows:
Submit Proper Documentation
Although aquatic therapy is reimbursed by insurance payers, failing to document the medical necessity of the procedure may lead to denials. Furthermore, there are exclusive details that the payer expects from you in the paperwork of CPT code 97113. It includes:
- The patient’s diagnosis and history.
- Any functional limitations faced.
- An explanation of why aquatic therapy is the most effective option.
- An answer to how it addresses specific needs.
- Specific goals of aquatic therapy.
- Exercises performed and patient progress.
- Duration of therapy session.
- Total direct time spent by the provider with the patient.
Do Not Unbundle Services
One of the common mistakes that most professionals make while billing is separately billing occupational therapy services, such as gait training or manual therapy. This billing approach is wrong, and the payer will reject your reimbursement request. You can bill occupational therapy services performed under water with CPT code 97113.
Use the Medicare 8-Minute Rule
CPT code 97113 is a time-based code. By definition, it means that you can bill 1 unit of 97113 if the session lasts up to 15 minutes. However, according to Medicare’s 8-minute rule, a physical therapist can bill 1 unit of CPT 97113 if he spent at least 8 minutes of direct one-on-one time with the patient, even if the remaining minutes were spent in preparation and documentation.
Follow Payer-Specific Rules
Yes, Medicare covers the CPT code 97113, but does that guarantee that every insurance payer will cover it? No! Commercial insurance payers have their own rules and reimbursement rates, which vary in each state. So, you may face a challenge navigating a variety of rules. The best solution to this problem is to carefully read each payer’s guidelines and file claims with full compliance.
Conclusion
With that being said, we conclude our guide on CPT code 97113. Hopefully, you now have all the essential information required to bill this code with confidence.
However, if you are still unsure or are still receiving denials for your aquatic therapy claims, consider acquiring professional physical therapy billing services from MediBillMD. They have a team of expert medical billers who have maintained a 97% rate of claims that are accepted on the first attempt. By collaborating with their team, you can successfully file clean claims and secure proper reimbursements.
