Massage therapy and PT

Since well before the Affordable Care Act, massage therapists have been struggling for recognition in the medical community. Alternative care in general suffered from a pretty low opinion, but massage was often lower still. So many insurance policies covered chiropractic and acupuncture treatments without covering massage. Somehow the fact that a massage made you “feel good”, as opposed to having your joints forcibly popped or getting needles stuck into your back, disqualified it from being a part of Serious Medical Care.

And so we fought with insurers and lawmakers about how massage should be treated like the CAM service it already was. The professions already went hand-in-hand, with so many massage therapists working in chiropractic offices, and with LMTs, LAcs, LCs, and NDs so often found under the same roof. Complementary and alternative care in general has such a broad variety of uses, and no single modality should be excluded.

Even though I knew that the changes would not happen immediately, when the Affordable Care Act took effect I assumed that before too long massage would gain its proper place alongside other CAM treatments. Alternative care of all kinds for everyone!

What’s happening with more and more insurance plans, however, is that massage is being thrown in an entirely different category than its CAM brethren. Massage is considered by these insurers to be a type of rehabilitative care, akin to physical therapy.

On the one hand, that’s pretty cool. Physical therapy is undeniably a medical treatment. If massage is like PT, that means massage has earned recognition as a medical treatment. Nice!

On the other hand, being a “rehabilitative therapy” instead of a “CAM therapy” means that massage is not as accessible as its companion modalities. In these insurance plans, chiropractic care and acupuncture treatments are available without needing to meet any deductible first, making them perfect for wellness and preventative care. Massage, however, is trapped behind (sometimes unreachable) deductibles, forcing the client to pay out of pocket for treatment or forego treatment entirely.

I get why they’ve done this, I suppose. The code I use to bill for massage (CPT 97140) is identical to one of the codes that physical therapists use. It’s actually considered a PT code by many insurance companies. And since Section 2706 mandates that insurers cover services based on the type of treatment as opposed to the type of practitioner, this is, in a way, less discriminatory.

But it still leaves me with a very bad taste in my mouth. Because by treating massage therapists in this way, insurers have declared that massage has no place in wellness or preventative care. We shouldn’t be giving massages that feel good (and help prevent future issues); we should only give massages that solve immediate problems.

If that’s the case, then where does rehabilitation end and relaxation begin? What a loaded question.

More and more – and this is true for providers in all physical medicine modalities – I have had to justify to insurers why my treatments are medically necessary. I find myself constantly trying to convince insurance companies that my massages are rehabilitative and purposeful even if the treatment has gone on “too long” (their words) and my client should be completely healed by now.

I was denied coverage for a treatment last week because the insurance company didn’t understand why I haven’t fixed all of my client’s muscle problems completely and forever such that he’ll never be in pain ever again. When I say it like that, it’s easy to see why this is foolish.

You know what should define a medical need? A doctor’s referral. If a doctor writes that his or her client needs massages, those massages are – almost by definition – a medical necessity. And yet, in practice, they don’t make a difference. Somehow insurance companies have convinced themselves (and the public) that they know best, even through they’re driven by profit over anything else.

Going back to my original point, I can’t say that I can see a clear resolution for this mess. The two billing codes* that massage therapists use are considered to be physical therapy codes, and therefore subject to physical therapy reimbursement requirements. It’s not just LMTs – if a chiropractor gives a pre-adjustment massage, this is also treated as rehabilitative treatment. The difference, of course, is that a spinal adjustment is a chiropractic code, and covered like a CAM treatment.

Should CPT 97124 and 97140 be considered the domain of LMTs, and covered in the same way that other CAM care is covered? Or maybe physical therapy should be available without a deductible? Some insurance companies already do that, and I’d be interested to see if it makes a difference in spending. If the insurance companies are all about the money, that might be our only chance of getting the point across.

* Depending on the insurer, sometimes both CPT 97140 and 97124 are considered PT codes, and sometimes only 97140 is. In the latter case, 97124 is either not covered at all or reimbursed at a lower rate.