October 22nd, 2014
Q: Is it appropriate to use 97022, whirlpool, to report dry hydromassage?
A: The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines:
Do not select a code that merely approximates the service provided. If no such service or procedure exists, then report the service using the appropriate unlisted procedure or service code.
Decision Health offers this additional plain English description:
Code of a heated whirlpool bath, e.g. to aid in debridement (removal of dead tissue and other material from a wound) or exercise.
In addition, National Government Services, a Medicare Contractor offers these guidelines (not directed at Chiropractic Physicians since 97022 is not a covered service for DCs. None-the-less it does provide insight into Medicare views, which many payers rely upon):
CPT 97022 – Whirlpool (to one or more areas)
Whirlpool bath treatments typically do not require the unique skills of a therapist. However, therapist supervision of the whirlpool modality may be medically necessary for the following indications:
- a condition complicated by a circulatory deficiency or areas of desensitization;
- an open wound which is draining, has a foul odor, or necrotic tissue;
- exfoliative skin impairments.
If greater than 8 visits are needed for whirlpools that require the skills of a therapist, the documentation should support the medical necessity of the continued treatment.
Only 1 unit of CPT code 97022 should be billed per date of service.
Dry hydrotherapy massage (also known as aquamassage, hydromassage, or water massage) is considered investigational and is non-covered.
In the Cigna HealthCare Coverage Position document, it identifies the hydro-bed as an "unproven and experimental procedure".
This information suggests that payers generally would consider this code to be used for wound debridement, and not for muscle relaxation or circulation, which would be considered experimental. Furthermore, aquamassage beds can be found in a shopping mall setting, which implies that clinical skill is not required to use it. Many payers will not reimburse for services that do not require clinical skill.
The following bullet is listed under Common Coding Errors defined by the American Chiropractic Association:
- CPT code 97039, unlisted modality, should be reported for hydro-bed, dry hydro-bed, aqua-bed, etc. Despite suggestions by some manufacturers and/or suppliers of these devices, it is inappropriate to report this service as 97022, whirlpool. The work involved in whirlpool includes assisting the patient in and out of the pool, and cleaning and disinfecting the equipment.
The Ohio State Board issued a similar statement in 2011: http://chirobd.ohio.gov/Portals/0/pubs/2011%20Newsletter%20June.pdf
In a 2005 article found in the American Chiropractor magazine, an attorney cited a case where a chiropractic physician was found guilty of erroneous billing for using the 97022 for dry hydromassage.
Cornerstone Medical Management researched several national insurance carriers for their policies regarding the use of the “hydro-bed” for 97022 and they concluded this:
These massage tables use heat and water to provide relaxation to muscles. Known as dry hydrotherapy, aqua massage or hydro massage all three carriers reviewed had policies that clearly stated the use of these tables in considered “experimental, investigation or unproven” for any condition. Hydrotherapy beds are mistakenly billed as 97124 or as 97022 – whirlpool. If billed to insurance, CPT 97039 – Unlisted modality should be used.
In addition, many payers claim that the use of the 97022 code to express specific types of aqua-massage is fraud and abuse because the equipment does not say "whirlpool," and/or because there is no water-to-skin contact.
However, in 1995, the AMA’s CPT Assistant summer newsletter explained that some revisions were made to the Physical Medicine and Rehabilitation codes to further reflect current practices in physical medicine and rehabilitation. The article added the following information to expand on the definition of “whirlpool”:
“Use of hot or cold water agitated by motors with current being directed at or away from the involved body part to achieve the desired effect. Useful in promoting muscle relaxation (heat), or reduction of muscle spasm or spasticity (cold), and improving circulation and movement. This modality can also be used to clean wounds (sterile whirlpool).”
This would support the use of this code when the goal is to promote muscle relaxation and reduce spasm, which is consistent with dry hydromassage. Also, CPT codes focus on procedure and functions, not specific equipment names. Lack of the word “whirlpool” in the equipment description may not be as important as how well the service matches the purpose of the procedure. The expanded 1995 definition would appear to accommodate the more current technologies of dry hydrotherapy.
Further, no resource appears to state that there must be water-to-skin contact. An article from the American Academy of Professional coders (Nov. 1, 2012) as well as CPT Assistant (May 1998) mention that 97022 is appropriate for “dry whirlpools” in the context of would care. Therefore, it is not necessary for the patient to get wet.
In light of the above information, it appears that there is conflicting information from authoritative sources. If a payer claims to follow CPT guidelines, then a case may be made for the use of 97022 for dry hydrotherapy. However, when looking at CMS and other payer guidelines, as well as requirements for the application of clinical skill, many payers will likely deny the use of this code for those services. In these cases, 97039, unlisted modalities, may be more appropriate. This code should be accompanied by a report which outlines why the service would be considered medically necessary and outlining how it helps the patient, and why it requires clinical skill to administer. Additionally, most states do require that providers collect an authorization identifying these type of procedures. These authorizations must be signed by patients prior to treatment of this type of procedures that indicates the patient's acknowledgement that he/she will be receiving this "unproven/experimental procedure", which means that they may be required to pay for it out of pocket.