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.

The Value of Massage

What is the value of massage?

I see this question as having two different meanings. The first one, referring to the monetary value of a massage, has a pretty easy answer. Depending on the city or town in which the massage is given, it’s typically valued at somewhere between $60 and $85. But the second meaning, the intrinsic value of massage, is much more complex. What is a massage worth?

Well, it depends on several factors. First of all, what is the goal of the massage? Is it for wellness? Prevention? Is it for physical pain? Stress relief? All of the above?

But just knowing the goal won’t answer the earlier question. How important is that goal? Is a client coming in for massages because she’s training for a marathon and wants to keep her legs and knees healthy? Is she coming in because she’s lived in pain for three years and has just now decided to do something about it? Which massage is worth more?

A new client is coming in for his first massage ever because he’s having the most stressful week of his entire life. A different client has been living under constant stress and pressure for years and has been coming to see you every month. Who will value their massage more?

But then, does it even matter?

In some sense, it doesn’t matter. A massage that someone values and appreciates is valued and appreciated regardless of its intent. But what happens when the intrinsic value of a massage comes into conflict with its monetary value? Let’s say that you suddenly have to start budgeting for expenses. Which items are the first to go?

I have some clients who are willing to pay for their frequent massages out-of-pocket because they know it’s what they need. I offer pretty good deals and discounts to help them out, to reward them for their commitment to getting healthy, but the fact still remains – this is money that they could spend elsewhere that they are spending on a massage.

I have other clients – well, potential clients – who cancel their appointment when it turns out that insurance won’t cover it. They know they could benefit from a massage, but it isn’t important enough to make the changes necessary to afford it. Sure, I know that some of these clients couldn’t afford to pay full price even with a modified budget. But not all of them. Clients from both of these groups – those who find the financial means to get a massage, and those who don’t – might have the same muscle problems, the same pain and tension. But they each assign a very different value to the massage.

As insurance coverage expands to cover more people and more services, I hope that the intrinsic value of massage will cease to be overshadowed by its monetary cost. No longer will financial considerations be the determining factor for whether someone receives appropriate treatment. Coming in for regular massages will be a thing that people do, not merely a thing that people dream about.

Likewise, as insurance coverage expands to cover more health care practitioners, the role of the massage therapist will change. What I hope most is that this will help to lend some legitimacy to our field. We are healers; we are medical professionals. I want people to know that massages can be uniquely beneficial for reasons far and wide. There is value in what we do.

In time, I hope that this means insurance companies will start to value our services as well. A solution to carpal tunnel pain that doesn’t involve expensive surgery? An answer to chronic back pain that doesn’t include a lifetime prescription to painkillers? I want to be put in the same category as other CAM providers, and not be overlooked or singled out as unworthy.

Sure, I have high hopes. But I think we’re on the right track.

Massage Regulations by State

As I mentioned previously, I want to use this space to teach any and all interested massage therapists how to get credentialed with insurance companies, bill for insurance, and get paid. This will be vital knowledge when the bulk of the ACA rolls out next year and insurance coverage is expanded to include more consumers and providers.

You may not be able to use some of this information instantly. Maybe you’ll tuck it away until the time comes when your state allows you to join an insurance panel, or when your first insurance client schedules a massage with you. Regardless of whether your state yet allows you to do the things I’m teaching you how to do, I’ll continue to present this information throughout the coming months. I want you to be ready.

But which states already allow credentialing? Which states will allow credentialing? Section 2706 specifies that the non-discrimination law applies only to providers who are licensed or certified under state law. If a state doesn’t have laws in place for massage therapist licensing or certification, they will not be able to take advantage of the new law.

But that doesn’t mean all hope is lost. Indeed, many of the remaining states that don’t have state-wide requirements are pushing to make licensing or certification mandatory. Idaho, for example, will be requiring licenses for massage therapists starting in July. We still have the rest of the year to affect change elsewhere.

Below is a list of every state and their regulations on massage, along with a link to their massage therapy board or professional division. If you’re curious about how your state intends to transition with regards to the Affordable Care Act and massage therapy coverage, these are the people to ask.

Alabama – State license required.
Alabama Massage Therapy Board

Alaska – No state requirements or regulations.
Alaska Department of Commerce, Community, and Economic Development

Arizona – State license required.
Arizona Board of Massage Therapy

Arkansas – State license required.
Arkansas State Board of Massage Therapy

California – Voluntary certification for therapist or practitioner.
California Massage Therapy Council

Colorado – State registration required.
Colorado Division of Professions and Occupations

Connecticut – State license required.
Connecticut Department of Public Health & Addiction Service

Delaware – Optional state licensing. Can alternatively choose to be a Certified Massage Technician.
Board of Massage and Bodywork

District of Columbia – State license required.
District of Columbia Board of Massage Therapy

Florida – State license required.
Florida Board of Massage Therapy

Georgia – State license required.
Georgia Board of Massage Therapy

Hawaii – State license required.
Hawaii State Board of Massage Therapy

Idaho – State license will be required as of July 1, 2013.
Idaho Board of Massage Therapy

Illinois – State license required.
Illinois Department of Financial & Professional Regulations

Indiana – State certification required.
Indiana State Board of Massage Therapy

Iowa – State license required.
Iowa Board of Massage Therapy

Kansas – No state requirements or regulations.
Kansas State Business Licensure

Kentucky – State license required.
Kentucky Board of Licensure for Massage Therapy

Louisiana – State license required.
Louisiana Board of Massage Therapy

Maine – State license required.
Office of Licensing and Registration: Massage Therapists

Maryland – State license (LMT) or state registration (RMP) required.
Maryland Board of Chiropractic and Massage Therapy Examiners

Massachusetts – State certification required.
Massachusetts Board of Registration of Massage Therapy

Michigan – State license required.
Michigan Board of Massage Therapy

Minnesota – No state licensing; licensing is regulated by city or county.
Minnesota State Legislature

Mississippi – State license required.
Mississippi State Board of Massage Therapy

Missouri – State license required.
Missouri State Board of Therapeutic Massage

Montana – State license required.
Montana Board of Massage Therapy

Nebraska – State license required.
Nebraska Department of Health and Human Services

Nevada – State license required.
Nevada State Board of Massage Therapists

New Hampshire – State license required.
New Hampshire Department of Health and Human Services

New Jersey – State license required.
New Jersey Board of Massage and Bodywork Therapy

New Mexico – State license required.
New Mexico Massage Therapy Board

New York – State license required.
New York State Board of Massage Therapy

North Carolina – State license required.
North Carolina Board of Massage and Bodywork Therapy

North Dakota – State license required.
North Dakota Board of Massage

Ohio – State license required.
State Medical Board of Ohio

Oklahoma – No state requirements or regulations.
Oklahoma Board of Medical Licensure and Supervision

Oregon – State license required. Insurance credentialing available.
Oregon Board of Massage || Oregon Practitioner Credentialing Application

Pennsylvania – State license required.
Pennsylvania State Board of Massage Therapy

Rhode Island – State license required.
Rhode Island Department of Health

South Carolina – State license required.
South Carolina Massage and Bodywork Panel

South Dakota – State license required.
South Dakota Board of Massage Therapy

Tennessee – State license required.
Tennessee Board of Massage Licensure

Texas – State registration required.
Texas Department of State Health Services

Utah – State license required.
Utah Division of Occupational and Professional Licensing

Vermont – No state requirements or regulations.
Vermont Office of Professional Regulation

Virginia – State certification required.
Virginia Board of Nursing

Washington– State license required. Insurance credentialing available
Washington State Department of Health || Washington Practitioner Credentialing Application

West Virginia – State license required.
West Virginia Massage Therapy Board

Wisconsin – State certification required.
Wisconsin Department of Safety and Professional Services

Wyoming – No state requirements or regulations.
Wyoming Professional Licensing Boards

AMTA Industry Fact Sheet

AMTA (American Massage Therapy Association) just released their Industry Fact Sheet for 2013. You should read it – it has all sorts of good information. Here are some of my favorite statistics:

How many massage therapists are there?

  • It is estimated that there are 280,000 to 320,000 massage therapists and massage school students in the United States.
  • According to the U.S. Department of Labor in 2012, employment for massage therapists is expected to increase 20 percent from 2010 to 2020, faster than average for all occupations.

Who gets massages?

  • Between July 2011 and July 2012, roughly 34.5 million adult Americans (16 percent) had a massage at least once, including 22% of women and 10% of men.

Why do they get massages?

  • Forty-three percent of adult Americans who had a massage between July 2011 and July 2012 received it for medical or health reasons.
  • Of the people who had at least one massage in the last five years, 43 percent reported they did so for health conditions such as pain management, injury rehabilitation, migraine control, or overall wellness.
  • Eighty-nine percent agree that massage can be effective in reducing pain.
  • Thirty-two percent of massage consumers had a massage for relaxation/stress reduction between July 2011 and July 2012.

How do people decide to get a massage?

  • In July 2012, more than fifty million American adults (16 percent) had discussed massage therapy with their doctors or health care providers in the previous year.
  • Of those 16 percent who discussed massage with their doctor or healthcare provider, 50 percent of their doctors or health care providers strongly recommended massage therapy/encouraged them to get a massage, compared to 45 percent in 2011. While physicians led the way in recommending massage (61 percent vs. 52 percent in 2011), chiropractors (43 percent vs. 50 percent in 2011) and physical therapists (38 percent vs. 49 percent in 2011) also recommended massage therapy when their patients discussed it with them. Twenty-five  percent of nurses recommended massage in 2012 versus 26 percent in 2011.

Massage and Healthcare

  • More than half of adult Americans (61 percent) would like to see their insurance cover massage therapy.
  • The vast majority of massage therapists (97 percent) believe massage therapy should be considered part of the health care field.

Integrative Care

I want to take a moment to explain some important but potentially confusing terms that I’ll be using on this blog. Specifically, I want to explain the difference between “integrative medicine” and “integrative healthcare”, at least in how I’ll be using them.

Integrative Medicine: This is another term for complementary and alternative medicine (CAM). CAM providers tap into a large pool of knowledge for their techniques, integrating Western medicine, Eastern traditions, and everything in between into their practice. Every LMT may say that they give massages, but no two massages are the same. Integrative medicine is also the union of various CAM techniques across disciplines, whether it’s naturopaths who give adjustments, massage therapists who perform fire cupping, or acupuncturists who utilize myofascial trigger points.

Integrative Healthcare: This term refers to the creation of an integrated system of care, in which all providers are able to utilize their expertise and deliver the most effective, comprehensive healthcare to the consumer. In an integrative healthcare system, a patient will have access to an acupuncturist just as readily as a primary care physician.

Integrative medicine has made huge leaps in the past few decades. Every day I come across new articles about how acupuncture can help with arthritis, massage is great for chronic back pain, and so on. If you mention “alternative care” in conversation, chances are good that people will know what you’re talking about.

With the implementation of the Affordable Care Act, which recommends the establishment of healthcare “teams” as well as a focus on preventative care, the national dialogue is shifting. Preventative medicine means cholesterol screening and mammograms, but it also means eating healthy and working out the kinks in your muscles before they become serious problems. Those who write the laws have realized that integrative healthcare is the only way to achieve the goal of providing comprehensive care to all Americans.

The conversation is changing. It’s time to listen.