Basics of CPT code 97116

The provider instructs the patient in the proper ways of practicing various exercises, including climbing stairs, focusing on one or more areas, that assist them in walking comfortably and without strain for a period of 15 minutes. Below is the code description for CPT code 97116.

97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

The qualified health care provider trains the patient in specific activities that will facilitate ambulation and stair climbing with or without an assistive device. Proper gait sequencing and safety instructions are included when appropriate. This code requires direct contact by a qualified health care provider with the patient and is billed in 15-minute units. A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97116 to be billed.

It is appropriate to bill the 97116 CPT code when a patient requires gait training to improve their walking abilities due to a health condition, injury, surgery, or amputation. The patient must be expected to show improvement in their walking abilities with the help of gait training for the procedure to be considered medically reasonable and necessary.

Documentation required for CPT code 97116 

Gait training Includes sequencing, training using a modified weight-bearing status, employing assistive devices, and completing turns with proper form. If you are using this code, make sure you are focusing on the biomechanics of the gait cycle in some form or another. Having a patient walk in order to improve cardiovascular health is not considered gait training.

• This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma.
• This procedure is not medically reasonable and necessary when the patient’s walking ability is not expected to improve.
• Repetitive walk-strengthening exercise for feeble or unstable patients or to increase endurance do not require provider supervision and will be denied as not reasonable and necessary.
• The medical record should document the distinct treatments rendered when gait training for a lower extremity is done during the same visit as orthotic fitting and training (97504), prosthetic training (97520), or self-care/home management training (97535).

The time counted is the time the patient is treated. For gait training in a patient with a recent stroke requires both a therapist and an assistant, or even two therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can count as only one unit of 97116 CPT code. The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.

CODING GUIDELINES for Procedure code 97116

• One-on-one therapy code
• Billed in 15-minutes increment
• Require a therapy modifier (GP, GN, GO, CO, CQ)
• CMS 8-minute and AMA rule of Eights are applied

Reference;

https://e2emedicalbilling.com/97116-cpt-code

https://www.aapc.com/codes/97116