When the pandemic hit, many physical therapists made the leap to telehealth out of necessity—and in the process, helped unlock the potential of virtual care for a variety of cases. Today, in-person visits are back to the norm, but telehealth remains a proven option for some clinics and a preference for some patients. Teletherapy allows physical therapists to reach patients that may be immunocompromised, reside in an area with little or no access to PT, people who cannot travel far, or some who just prefer the comfort of home.
With a little bit of creativity, a significant number of physical therapy diagnoses can be treated virtually. However, it is imperative to understand the current and future costs and reimbursements by Medicare and commercial insurance payers as well as the most effective treatments to perform via video for maximum patient outcomes and satisfaction.
Virtual treatment options
Telehealth can be an excellent option for many patients, but it is essential that therapists have a good understanding of the most effective treatments that can be completed virtually. This will ensure the patient stays on the right recovery path, and has a positive experience with outcomes that are on par with in-person visits.
It should come as no surprise that a large component to effective physical therapy treatment is exercise. This is the easiest treatment to teach and observe via video.
Specialized equipment is not necessary for patients to perform a variety of exercises in their own homes. Physical therapists can utilize body weight exercises such as sit-to-stands, squats, planks, clamshells, bridges, and many more to great effect. Along with that, active-assisted types of exercises (ex. using a broomstick to help in raising the arm overhead) can also be demonstrated and performed with some household objects.
The addition of resistance bands provides even greater variety for everything from rotator cuff rehab to ankle sprains and hip strengthening. Other common pieces of equipment some people already have on hand or can track down for relatively cheap are exercise balls and foam rollers. Exercise balls are not only great for core strengthening but can also be used to promote overhead shoulder mobility and seated balance. Foam rollers can not only be used for self-massage of IT bands and quads, but also for shoulder and thoracic mobility.
Another added benefit of having patients perform home exercises via video is, once they have certain exercises down, they have flexibility on where and how they can complete their home exercise programs.
Manual therapy alternatives
Although the hands-on part of physical therapy is impossible to do via video, there are some effective alternative applications. Teaching a patient to perform a self-mobilization of either joints or soft tissue is an empowering treatment for patients. Not only are patients increasing their self-efficacy, but you are providing a valuable skill to help manage and improve their symptoms.
Some common areas that are easy to treat via self-mobilization include the cervical and thoracic spine and hips. Cervical rotational and extension Sustained Natural Apophyseal Glides (SNAGs) can be taught and performed to improve neck mobility and reduce pain. Thoracic extension over a foam roller or a towel roll placed on the back of a chair are also good options to improve thoracic mobility. Self-mobilization of the hip can be done with a little creativity as well by utilizing a heavy resistance band or yoga strap. Manual therapy with a targeted trigger point type of massage can be performed by using a tennis ball in a pillowcase and leaning into it against the wall, and repositioning as necessary to massage a muscle knot in the thoracic region.
Patients can easily be instructed in the appropriate use of hot/cold packs to ease their pain and discomfort. In addition, if patients would like to go a step further for pain relief, an electrical stimulation therapy unit could be purchased and the physical therapist could instruct on the appropriate use, duration, and placement of the pads.
Deciding where to treat
Virtual evaluations and treatments
The most crucial part in developing effective treatment strategies, whether in-person or over video, is a thorough evaluation and diagnosis to guide the plan of care. Virtual PT assessments have been shown to be as reliable as in-person clinic visits for some common musculoskeletal diagnoses, including: low back pain, and shoulder, knee, ankle and elbow joint dysfunction. They are even as effective as conventional therapy for patients following a total knee replacement.
A hybrid approach
Depending on patient preference, primary complaint, mechanism of injury, physical location, and access to physical therapy, it may be most beneficial to perform an evaluation in-person—which could be followed up with virtual visits. For instance, patients with a pelvic health concern may be best served by at least an in-person evaluation first to get the best possible perspective on treatment with the highest likelihood of outcomes. In many recovery scenarios, patients may then have the option to alternate between in-person and virtual care to suit their preferences and needs.
Strictly in-person therapy
In order to keep patients safe and reduce the risk of falls, some treatments are best performed in clinic where therapist is close by for support, such as:
- Balance interventions for a patient with a neurologic condition
- Diagnosis and treatment of vestibular dysfunction
- Gait training and/or instructions on the use of an assistive device
Coverage and reimbursement rates for telehealth
Before treating patients virtually or with a hybrid approach, it is important to have a clear understanding of the insurance coverage and ongoing legislative developments. First, let’s discuss Medicare as they typically set the tone for what commercial insurance payers provide.
Treating patients with Medicare coverage continues to be an evolving discussion. During the public health emergency in 2020 due to the COVID-19 pandemic, the Center for Medicare and Medicaid Services issued a waiver to expand the list of healthcare providers who could provide telemedicine to include practitioners who are eligible to bill Medicare, such as physical therapists. This waiver was extended through the Consolidated Appropriations Act, 2023, allowing PTs to treat patients via telemedicine through 2024. Medicare has provided a list of CPT codes payable for services provided through telehealth. Most physical therapy codes are covered, but if you have any questions about a specific code, it is best to consult the most recent fee schedule.
Commercial insurance payers
Commercial insurance payers differ in the types of physical therapy services and duration for which they will include telehealth coverage. The APTA summarized coverage of telehealth services by commercial payers, however the expiration dates and policy specifics vary widely. It is best to consult with your contracted providers as well as review state laws governing telehealth services for the most current information.
Determining the appropriate rate to charge for virtual visits will depend on the state in which you do business if you are working with commercial insurance. Most states have a private payer law which discusses telehealth reimbursement, however not all have a specific parity law. A parity law in this case essentially states that commercial insurers will pay the same rate for virtual services as for those done in-person within the clinic. If instead, if your clinic has a self-pay structure, it is more common to charge the same or slightly less for virtual visits than for in-person.
Telehealth can be an integral part of a physical therapy practice. With that said, some patients will prefer to have an option of telehealth while others will want to commit to in-person and hands-on care. You should create a winning partnership with them that meets their needs and also sets them up for success as best as possible. By considering the most effective treatments and easily treatable diagnoses, and working with them on the plan they’re most likely to follow, you can ensure patients will achieve great outcomes whether attending therapy fully in-person or with some virtual visits worked in.
About the author:
Chelsea Krotser is an outpatient orthopedic physical therapist and freelance writer. Drawing on her experience as a PT as well as her former life as an accountant, she is dedicated to providing an insightful clinical and business perspective. She loves writing about all things related to physical therapy. You can find her on Instagram @chelseakrotser.