"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Sunday, May 18, 2008

Is the Nintendo Wii Skilled Physical Therapy?

You can go buy the Nintendo Wii Gaming System from Circuit City for $249.99.

I haven't done this but I could buy the Nintendo Wii Gaming System and use it in my physical therapy clinic billing patients for Therapeutic Activities (97530) or Therapeutic Exercise (97110) all day long.

You could also buy the Wii Fit Balance Board from Circuit City for $89.99 and put that in your physical therapy clinic, too.

Apparently, many physical and occupational clinics have done just that.

"Herrin Hospital in southern Illinois, about 100 miles southeast of St. Louis, bought a Wii system for rehab patients late last year.

At Walter Reed Army Medical Center, the (Wii) therapy is well-suited to patients injured during combat in Iraq, said Lt. Col. Stephanie Daugherty, Walter Reed's chief of occupational therapy."
I live in a resort community on the west coast of Florida and many of my retired patients would love to come to me for rehabilitation focused around their tennis or golf lifestyles.

Some physical therapists have declared that Wii is inappropriate in the physical therapy clinic,. Larry Benz is a physical therapist with a large following who has posted on multiple occasions at MyPhysicalTherapySpace.com about his displeasure with the Wii.

My position on the Wii (and technology in physical therapy in general) is this: Does it help the patient?

If technology (including the Wii) is good for the patient then we should consider its use.

I have not ready Larry Benz' every post so maybe he has already brought this next point up.

Is Wii skilled therapy?

Every third-party payer requires physical therapy be skilled physical therapy. Most insurance contracts have a 'boilerplate' section that mentions this.

Only Medicare has police powers so we usually just talk about Medicare requiring evidence of skilled therapy in the daily Treatment Encounter Notes.

Transmittal 88 has a specific definition of skilled therapy, as follows:

"Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period." (page 25)

This next section is repetitive but bears on the Wii issue...

"Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services." (page 42)

What is missing from the Wii debate is the diagnosis.

What is the specific impairment, addressed by the Wii, that is addressed that when treated, will significantly improve patient function?

Also from Transmittal 88...

"A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant."(page 27)

To paraphrase Hippocrates, "First, a physical therapy diagnosis".


  1. Tim,

    I appreciate your comments. I like how you raise the question of is this skilled PT. I do think for some patients it most certainly would be and for some it would not be. This is no different than the use of a treadmill. We don't question the use of a treadmill as part of physical therapy treatment. Yet I again I must add that for some patients a treadmill would be skilled and for others it would not be. I do not think it is in the tool being used that should determine the level of skilled intervention but how it is being used. This is where we must rely on ethical practitioners.

    What frustrates me the most is that in my 10 years of practice I have seen more unethical practice than I care to admit. In considering purchasing a wi I am grateful for the points you raised and I think it is up to all of us to demonstrate skilled therapy. Whether it be on a treadmill, bike, exercises or in the use of a wii gaming system.

    Best Regards,

  2. Since I first posted this (May 18, 2008) I have bought a Wii, we use it a lot and, yes, I think it can be skilled therapy.

    Documentation is important and I think it's just a matter of time before some entrepreneurial PT markets a PT Wii that can generate clinical data, evidence of Medicare compliance and outcomes data that will qualify for PQRI.

    Electronic Exercise Interfaces (EEI) like the Wii, are not a fad - they are the future.



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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

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