This page contains information and helpful tips about documentation & billing in aquatic therapy.
Documentation:
Know your client’s diagnosis and deficits- Always document how the client’s participation in aquatic therapy is facilitating progress towards their functional goals and occupational performance on land.
Ensure you are documenting in a way that clearly demonstrates and measures your client’s functional progress. Document areas in which your client is improving and how your skilled interventions in the water are carrying over onto land/getting them back to their PLOF in daily occupations.
Exercises or activities done in the water to simply improve or maintain overall fitness level are NOT covered by insurance! Everything done in the pool must have a functional purpose and demonstrate why your client is benefiting from aquatic therapy vs. traditional land-based therapy. Always justify the use of the water.
Ask yourself this question: “Why am I referring this client to aquatic therapy?”
Document the deficits and objective impairments your client presents with and ensure you are having them complete exercises/activities in the pool which will allow them to improve upon those deficits.
Consider how the various properties of the water are aiding in the treatment of your client and document this when necessary.
When a client is seen on land for a progress note, insurance update or re-certification, it is important to document their progress including which specific deficits or impairments have improved. As stated previously, justify the use of the water- Demonstrate how aquatic therapy has enabled your client to reach their goals, make progress on land, or improve participation in daily occupations.
Ex: The buoyancy of the water has allowed for the offloading of joints leading to an improvement to Fair+ dynamic standing balance on land.
Ex: Client is now able to complete toilet transfers independently due to her gains in strength and balance achieved while participating in aquatic therapy.
Documentation must demonstrate that the services provided in the pool were NOT repetitive. Ensure you are documenting how you are progressing your client in the pool or grading up the intervention (i.e., increased amount of weight, added equipment, etc.).
Always document your client’s pain level/location. Documenting their pain level on land vs. in the water can be helpful.
Always document how your client completes transfers into/out of the pool (ramp, stairs, chair lift, etc.) and the level of assist they require.
Documentation must demonstrate skilled aquatic therapy services. It is important to include details to portray this (purpose of your chosen interventions, level of assist/cues provided, how your client is progressing).
Document for each client in a SOAP (Subjective, Objective, Assessment, Plan) note format to paint a clear picture.
Billing:
CPT Code 97113 = Aquatic Therapy with Therapeutic Exercise
Everything done in the water/throughout aquatic therapy treatment sessions should be billed under this code
1 unit billed for every 15 minutes
Keep in mind that you might need to contact your client’s insurance company to verify coverage of aquatic therapy services.
In addition to coverage, it is also important to know whether prior authorization is required and if there is a limitation placed on # of visits.