Eli's Rehab Report

Question: We often use whirlpool to help cleanse patients' wounds. Our carrier recently told us that we used this modality too frequently for one particular patient and that they expected us to combine the whirlpool treatment with therapeutic activities. Should we appeal?

Virginia Subscriber

Answer: You should probably appeal. Although most payers require practices to limit modalities (97010-97028) to only 25 percent of a patient's total rehabilitation service hours, carriers usually make exceptions for wound care treatment.

The policy for Trailblazer Health Enterprises LLC (a Part B carrier in Virginia) states, "The use of modalities as stand-alone treatments is rarely therapeutic and usually not required or indicated as a sole treatment approach to a patient's condition ... Therefore, it is expected that a treatment plan consist predominantly of therapeutic procedures (such as codes 97110, 97112, 97116, and/or 97530), with adjunctive use of modalities during the initial or 'warm-up' phase."

But the policy does include a caveat, which states, "An exception would be the application of whirlpool in wound care."

Check your policy to determine whether the carrier publishes any frequency guidelines. If, for example, the payer only allows you to use whirlpool once a week per patient, they will deny your claims if you exceed that frequency. This may be the reason for your denials.

If you believe that you have not exceeded frequency limits, you should send a letter to your carrier explaining that you performed wound care on the patient, along with a copy of the payer's policy. Underline or highlight the section that offers the exception for wound care and ask the carrier to reconsider your claims.