97116 CPT Code: Know Your Codes
97116 CPT Code Description: Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing). The clinician instructs the patient in specific activities that will facilitate ambulation and stair climbing with or without an assistive device. Proper sequencing and safety instructions are included when appropriate. This code requires direct contact and may be billed in 15-minute units.
Basic Guidelines for 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.
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