Poorly Written Insurance Codes Cause Patients to Lose Care.
Poorly Written Insurance Codes Cause Patients to Lose Care.
In 2017 a speech pathologist was back charged $87, 202.22 by Horizon BCBS for including equine movement as one tool in therapy services. She correctly coded her services as speech therapy and was attacked for not using the S8940 equestrian therapy/hippotherapy code – which would be an automatic denial. She was in litigation with Horizon BCBS through March 2024 until the statute of limitations made Horizon BCBS drop the case. This tedious and expensive battle cost this therapist her practice, her piece of mind and left many children with special needs without services.
Across the country physical therapy (PT), occupational therapy (OT) and speech-language pathology professionals (SLP) integrate hippotherapy (medical quality equine movement) as one therapy tool in a patient’s plan of care, along with other therapy tools and/or strategies. These therapy services are based on medical necessity and require a physician referral, therapy evaluation, and follow practice standards for occupational, physical and/or speech language therapy.
Occupational, physical, and speech-language therapy professionals utilizing equine movement as part of a treatment plan can be reimbursed under Medicaid.
The American Hippotherapy Association, Inc. (AHA, Inc.), Professional Association of Therapeutic Horsemanship International, and American Horse Council have identified critical issues that are causing patients to have their services denied by Medicaid.
What’s the issue?
In practice, hippotherapy (medical quality equine movement) is utilized as a tool by licensed professionals who use their clinical reasoning to determine how to treat the patient as part of a larger plan that often involves multiple tools and strategies. It is NOT a standalone treatment method. Most of the time therapy services are coded under Therapeutic Procedures codes created in 1998.
The issue is that an insurance generated code (S8940) under the HCPCS Level II coding system was created over a two decades ago with incorrect language specifically targeting “hippotherapy” for automatic denial.
The code’s language is problematic for several reasons: it confuses PT, OT, and SLP professionals with Therapeutic Riding Instructors®, it classifies “hippotherapy” as a separate service instead of a tool used as part of PT, OT, and SLP treatment plans, and it considers the services provided as “experimental”. This is causing significant numbers of PT, OT, and SLP claims that include hippotherapy as one tool in part of a larger treatment plan to be automatically denied despite strong scientific support proving the medical benefits.
Industry professionals have approached Blue Cross Blue Shield Association (BCBSA), the private insurance company who created the code, to explain the issues. BCBS acknowledged the S8940 code was problematic and agreed to remedy the situation. Unfortunately they gave up as concerns were raised regarding potential lawsuits as the code had been used for automatic denials.
Further, BCBSA heads the HCPCS Level II coding committee. Industry stakeholders were advised by national therapy associations not to file a code deletion request because BCBSA is able to bury the request indefinitely.
The industry has been working hard to educate Medicaid providers on a state-by-state level, but the issue has come to a head. Several states still carry the S8940 code and providers are still getting automatically denied for using it.
Thirty-seven states potentially permit appropriate reimbursement but only Colorado has explicit legislation mandating Medicaid reimbursement for therapy using equine movement as provided by licensed PT, OT, or SLP therapists.
The S8940 code must be removed from the HCPCS Level II in order for patients to have their therapies appropriately covered and equine movement must be accurately described at the Federal level.
What can be done?
The AHC, PATH Intl, and AHA, Inc. recommends legislative action to protect the use of equine movement, often referred to as hippotherapy, as a standard practice therapy tool for occupational therapists, physical therapists, and speech-language pathologists. The industry also recommends hippotherapy be legally described at the federal level as “ equine movement as a tool in therapy services provided by a physical therapist, occupational therapist, or speech-language pathologist”, and that “therapy using equine movement” means therapeutic activities that leverage horse-human interactions to facilitate progression toward meeting therapeutic goals.