Eli's Rehab Report

Although physiatrists and therapists embrace the virtues of water modalities such as whirlpool (CPT 97022 , application of a modality to one or more areas; whirlpool) and Hubbard tank (97036, application of a modality to one or more areas; Hubbard tank, each 15 minutes), many practices still confuse the codes for these procedures, setting themselves up for denials and low reimbursement rates. The following list of commonly made errors and solutions will help these practices more accurately submit claims for proper payment of these therapeutic modalities.

Error #1: Billing 97022 and 97036 When Used for the Same Condition

A patient with osteoarthrosis of the ankle and foot presents for her weekly therapy session, at which she complains of more pain than normal in her ankle. The therapist places the patients foot in a whirlpool for 15 minutes and leaves the room. When the therapist returns, the patient has removed her foot from the whirlpool, stating that the angle at which she must hold her leg to keep her foot in the whirlpool has given her a cramp. The therapist immerses the patient completely in a Hubbard tank for 30 minutes, so the foot and ankle can receive more even coverage.

The therapist bills for the whirlpool using one unit of 97022 and for the Hubbard tank using two units of 97036. The claim for the Hubbard tank is rejected by the insurer, with a notation stating that it is not medically necessary to have more than one form of hydrotherapy during a visit.

Most carriers will not allow therapists to bill for both a whirlpool and a Hubbard tank for the same condition on the same date, says Paula Kingston, billing manager at Raleigh Physical Therapy, a two-therapist practice in Raleigh, N.C. The therapist has to look at the situation ahead of time and choose one. They can bill for only that modality.

The scenario above would be billed using two units of the 97036 code for the Hubbard tank, along with the ICD-9 code for osteoarthrosis of the ankle, 715.17.

If the therapist performed both modalities together, then found out after the fact that only one was payable, he or she should bill for the modality that lasted the longest amount of time in this case, the Hubbard tank. In addition, the Hubbard tank offers a higher reimbursement rate because it requires constant attendance, whereas the whirlpool is a supervised modality (so the patient can be set up with the whirlpool and then left unattended for a period of time.)

The Hubbard tank is more involved because sometimes it requires the therapist to use a lift to get a patient from a wheelchair into the tank, says Laureen Jandroep, OTR, CPC, CCS-P, owner of A+ Medical Management and Education, a coding and reimbursement consulting firm and a national CPC training curriculum site in Egg Harbor City, N.J. In addition, the patient could potentially slip under the water and drown, so the therapist has to be with him or her at all times.

Jandroep says most carriers allow for certain limited circumstances in which both modalities can be used, but these occasions are rare and require supportive documentation and proof of medical necessity. For example, a patient has a bedsore on her back and is put in the Hubbard tank to cleanse it; then later, the therapist has the patient immerse a carpal tunnel wrist in a whirlpool. The whirlpool might be necessary because the therapist would probably want the source of friction directly on the wrist, which isnt as easy to achieve in a Hubbard tank.

In these circumstances, the coder would bill 97022 with diagnosis code 354.0 (carpal tunnel syndrome), and 97036 with ICD-9 code 707.0 (decubitus ulcer). Some-times insurers overlook the different ICD-9 codes and still reject one of the modalities, says Kingston, so you might want to put a note in with the claim explaining the medical necessity for each modality and pointing out the different diagnoses.

Error #2: Billing 97022 and 97036 as 97140

Sometimes, misinformed therapists or coders document the performance of whirlpool and Hubbard tank properly in the patients chart but, faced with a history of denials when billing for these procedures together, choose to combine the time spent on these codes and bill the claim using 97140 (manual therapy techniques) or 97039 (unlisted modality).

Because HCFA allows therapists to code time units under eight minutes by adding the total therapy times together and bill using the modality code most used, there are people who think its OK to add together therapy times in any situation and bill that way, says Kingston. But you cant just add together times of modalities you know you arent supposed to bill together to increase your units.

And never bill for whirlpool or Hubbard tank using the manual therapy code (97140), says Jandroep. These modalities do not constitute manual therapy, so its incorrect to bill them that way. Because there is a more accurate code, you cant bill the unlisted modality code.

As in the first example, the modality that required the most time or with the highest RVU should be reported if 97022 and 97036 are performed together.

Error #3: Billing Fluidotherapy as Massage

Often, a therapist is working to increase a patients range of motion or circulation and will place the patients hand or foot into a whirlpool machine filled with crushed corn husks instead of water. This procedure, known as fluidotherapy, does not have its own CPT code, so many coders assign 97124 (massage), which they believe to be the most accurate because the patients hand is receiving massaging motions from the whirlpool machine.

Fluidotherapy is a supervised modality, so a therapist does not have to stay with the patient throughout the process, says Jandroep. Minimal supervision should be the first hint that a therapeutic procedure code should not be used. In addition, many states allow claims for 97124 to be submitted only by a licensed massage therapist.

Instead, says Jandroep, because fluidotherapy is a dry whirlpool, the correct code is 97022.

Error #4: Billing Separate Units of 97022

A patient with bilateral ankle arthralgia (719.47) requires whirlpool treatment three times a week for three weeks. The therapist places the patients right foot in the whirlpool for seven minutes, then places the left foot in the whirlpool for an additional seven minutes. The therapist bills two units of 97022 one for each foot. As a timed code, 97022 cannot be reported based on the number of extremities placed into the machine, only on the amount of time spent in the modality. Because the patients total treatment time in the whirlpool was 14 minutes, the coder should bill only one unit of 97022, along with the ICD-9 code for arthralgia of the foot or ankle, 719.47.