Semantics: To be Exuberant or to be Correct
By Barbara L. Glasow, PT
An exuberant therapist recently thought . . .”I just learned about the most wonderful new treatment that I have ever been involved with since becoming a therapist. It’s called hippotherapy!! The movement of the horse is almost magical with the results that can be achieved! I’m hooked! I’m going to stop using most of the other treatment approaches that I’ve used for 10 years and I going to become a hippotherapist and devote myself to learning everything I can about it. Then, I’m going to open a clinic devoted exclusively to the practice of hippotherapy and achieve amazing results. And then, we’ll need to do research to prove to everyone that this modality is the best treatment around for any patient with movement dysfunction. Where was this treatment when I needed inspiration in my career a few years ago?”
Enthusiasm and exuberance is wonderful. The energy we derive from something that excites us can carry us through some pretty rough times of rapid change in health care, increasing documentation demands, decreasing health insurance coverage and increasing scrutiny by managed care. Those of us who include hippotherapy in our practice would tend to agree that it is a very valuable treatment strategy and assists us in achieving functional outcomes sometimes more efficiently than with other means.
However, in these same times of increasing managed care, decreasing coverage and increasing scrutiny it is of critical importance that all therapists accurately state clearly what they are providing patients within their treatment plans and neither under nor overstate what is being done or why. Many of us have made hippotherapy out to be more than it really is and the word itself has not been helpful to us in gaining the recognition and reimbursement that we want for it.
Hippotherapy, from the word “hippos”, the Greek word for horse, was created by the Germans who use all kinds of compounds words in their language. Hippotherapy is a very logical word for them to create. It means “treatment with the help of the horse.” Physical therapists there get trained and certified and can say they are “hippotherapists”, physical therapists that treat with the horse, in the same manner as they have “hippologists”, people who train horses. As Americans, we have chosen to retain the use of the word, “hippotherapy”, thinking that it would be internationally easier to communicate with other professional colleagues around the world. Presently, over 24 countries are doing some type of medical treatment with the use of the horse and most are calling it hippotherapy.
In the United States, however, the use of the word “hippotherapy” is a very confusing term to physicians, researchers and third party payers. To them, the word hippotherapy implies that it is a unique and distinctly different treatment approach from what has ever been done before. In their eyes, it needs to be proven through research that it is effective; improves functional outcomes; and is as good as or better than other treatments. Until then they view hippotherapy as a new, emerging and investigational technology and so therefore it does not qualify for reimbursement at the present time.
When we argue that hippotherapy is a treatment strategy and not a modality or distinct treatment method it is argued back that other treatment tools don’t have the word “therapy” in it. An easy reply is that “Swiss therapy balls” are used in a wide variety of treatment procedures and are clearly treatment tools. But this does not make our lives any easier. Unfortunately, we have done such a good job of spreading the word about hippotherapy that we are probably stuck with the word for better or worse. So, all we can do is to take care in what we say about it.
We have all been guilty in misrepresenting what hippotherapy is or is not from NARHA to AHA to myself who wrote an article in 1984 “Hippotherapy – The Horse as a Therapeutic Modality”. Many clinicians casually use the terms “treatment tool” and “modality” interchangeably. As innocent as that is, the two terms mean very different things. Therapists use a wide variety of treatment tools (any instrument or device necessary to one’s profession or occupation) including gymnastic balls, scooters, balance beams, weights within the different treatment procedures of neuromuscular reeducation, therapeutic exercise or therapeutic activities. We expect to be reimbursed for the treatment procedure we provide NOT the treatment tool that is used. Modalities (“Any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.”) are very different from procedures and each require their own CPT code for reimbursement. Modalities must also be FDA approved and go through the investigational technology review of insurance carriers. It is very clear, when carefully thought about, that the horse is not a modality, yet how often have we referred to hippotherapy as such?
Many of us feel that we are able to achieve quicker and better functional outcomes with the use of the horse, and in the future, hopefully sufficient research will support this conclusion. In the meantime though, we need to be educating others that hippotherapy is an inclusive term that refers to all the ways the horse can be used as a treatment strategy. Hippotherapy is NOT one separate new treatment method. Instead, therapists use the horse in a variety of treatment approaches that been used in the therapy field for years, including the neurodevelopmental treatment approach, sensory integration, motor learning, motor control, psycholinguistics. The way the horse is used for each patient depends on the needs of the specific patient, the expertise of the therapist and the training of the horse.
When we refer to using the horse or equine movement as a treatment strategy within a therapeutic procedure it is then very appropriate to bill for units of service depending on how the strategy is used. APTA and AOTA have both agreed that use of the CPT codes 97110 (therapeutic exercise), 97112 (neuromuscular education), 97530 (therapeutic activities) or 97770 (sensory integrative activities) could all be appropriate codes depending on how the tool of the horse is used by a therapist within a treatment procedure. However, when therapists call the reimbursement department of APTA to inquire how the treatment approach of “hippotherapy” should be coded, APTA has been reluctantly but correctly recommending recently (since the Korokti administrative insurance hearing occurred) that therapists use the code 97799 (for unlisted therapeutic procedure) which then requires that additional documentation be submitted in order to be reviewed for reimbursement. In this case, the therapist has presented hippotherapy as a unique treatment and since it does not have its own code number, the unlisted procedure code should be used. If instead, the therapist inquires how to code a treatment session in which neuromuscular reeducation is used in order to improve the patient’s postural control, balance and body awareness and the horse is used as a treatment tool to assist in that process, APTA would concur that use of the code 97112 for neuromuscular reeducation would be appropriate. I think you begin to see the importance of how we state what we are doing.
Many of us state that we have hippotherapy practices or that we are hippotherapists. We offer hippotherapy programs and we often market hippotherapy as a unique treatment approach to potential patients. We probably all have stated something to that effect in the past. This is great from a marketing perspective but has helped in creating the insurance backlash that we are currently facing. How might we state more clearly and correctly what we are doing?
When we are trained in hippotherapy we do not become hippotherapists but remain therapists (physical therapists, occupational therapists, speech-language pathologists) that include hippotherapy in their practice.
We offer physical therapy services (or OT, SLP) that include:
- hippotherapy as a treatment strategy
- the use of the horse in treatment
- the movement of the horse in treatment
- equine movement in treatment. Hippotherapy can be a strategy of choice used by therapists within their treatments. The new definition of hippotherapy very succinctly states what it is and what it is used for. The hippotherapy certification exam, if passed, allows therapists to state that they are a hippotherapy clinical specialist, (a clinician that includes hippotherapy in their practice and has a high level of knowledge in hippotherapy). When we obtain prescriptions for treatment the prescriptions state PT, OT, or SLP not hippotherapy since the prescription needs to state the service that is being requested. (It may state “. . . that includes hippotherapy.”)
When we use semantics correctly it sometimes seems that it takes a lot spontaneity out of life. Is it really that important to be politically correct all the time? That’s a hard question. Many of us speak more casually when explaining to a lay person what treatment they will be getting and what it will do for them in less technical terms. However, if we want to get reimbursed for the treatment we need to document what we do in much more technical and medical terms. It seems that we need to clearly make the same distinction in semantics when we speak about hippotherapy. It may require a little reflection on our part to become aware of what we are saying and in doing so we may become better educators of others in what hippotherapy is really all about.
Summary of the Do’s & Don’t of Hippotherapy Semantics
- Hippotherapy is a treatment strategy NOT a modality, unique treatment approach, form of therapy or treatment.
- Hippotherapy is NOT new. It’s been used for over 20 years in the U.S. in treatment.
- Therapists are NOT hippotherapists nor do they practice hippotherapy or have a hippotherapy practice.
- Therapists DO include hippotherapy in their practice; use the horse as a treatment tool; use the horse in treatment; use the movement of the horse in treatment or use equine movement in treatment.
- Hippotherapy can be considered a “strategy of choice.”
- Hippotherapy can be considered an inclusive term that refers to all the ways the horse can be used as a treatment strategy by PT’s, OT’s and SLP’s.
When certified by the American Hippotherapy Certification Board the therapist is a hippotherapy clinical specialist