Gait training is an advanced and essential style of training. It is a type of physical therapy that helps individuals suffering from walking difficulties or loss of balance. This training is provided by physical therapists who utilize various exercises and techniques to enhance the patient’s flexibility and mobility.
However, with all these responsibilities, it is nearly impossible for them to focus on accurate medical billing. We are playing our part by explaining the billing of CPT code 97116.
CPT Code 97116 – Description
CPT code 97116 refers to a therapeutic procedure called gait therapy or gait training.
During this procedure, the physical therapist spends 15 minutes with the patient, where he instructs the patient in the proper ways of performing various physical activities, including
climbing stairs. The aim of this training is to focus on one or more areas that assist the patient in walking comfortably and without strain for 15 minutes.
Typically, gait training is required for improved balance, coordination, and functional mobility after a serious injury, illness, or medical emergency (like a stroke).
Scenarios Where CPT Code 97116 is Applicable
The following are some examples where CPT code 97116 can be accurately applied for billing purposes.
Post Stroke Rehabilitation
Suppose a 64-year-old man is admitted to outpatient therapy following a left-sided ischemic stroke. He seems to have lost his balance and is dragging his right foot when walking. His family hires a physical therapist to provide him with gait therapy.
The therapist helps him in heel-to-toe walking and practice turning methods while progressively lowering support during the training. In addition, the therapist teaches him how to walk safely on carpet and uneven surfaces and modifies the height of his quad cane. CPT code 97116 is appropriate because the sole goal of this session is to correct and retrain his gait pattern.
Parkinson’s Disease
Imagine a 70-year-old man with Parkinson’s disease. He faces issues while walking, such as a shuffling walk, and sometimes freezes when turning or entering a hallway. The physical therapist focuses on enhancing turning skills, managing forward lean, and avoiding festination when walking more quickly.
CPT code 97116 is applicable here because the session focuses on altering improper gait caused by a neurological issue.
Multiple Sclerosis
Let’s say a 29-year-old woman feels leg weakness due to a relapse from multiple sclerosis. She exhibits erratic foot placement, unsteady gait, and early exhaustion. The therapist teaches her energy-saving walking techniques, helps control her steps, and practices walking on different surfaces.
Here, the therapist can bill CPT code 97116 for his gait training services.
Applicable Modifiers for CPT Code 97116
You may apply therapy modifiers like GP, CQ, or modifier 59 to CPT code 97116 for increased coding specificity. Let’s discuss some of these below:
Modifier CQ
Modifier CQ is used to indicate that the physical therapist assistant (PTA) delivered the outpatient physical therapy services in whole or in part. Medicare mandates its use when filing claims for outpatient therapy services.
Modifier GP
You can apply the GP modifier to CPT code 97116 to indicate that the service was provided under an outpatient physician therapy plan of care.
Modifier 59
You can apply modifier 59 to CPT code 97116 when it is required to demonstrate that the gait training was a distinct service from another therapy service rendered on the same day.
CPT Code 97116 – Billing & Reimbursement Guidelines
Adherence to the following billing tips and reimbursement guidelines will help you prevent claim denials and payment delays.
Ensure the Accurate Use of 97116
Before you start billing this code, you must first comprehend the code. Keep in mind that CPT code 97116 is designated specifically for gait training exercises. Therefore, you cannot use this code for general exercise or ambulation. Moreover, you can charge his code for 15-minute intervals, adhering to the Medicare 8-minute guideline. This means that at least 8 minutes of direct, individual interaction with the patient is required to bill for one unit.
Establish Medical Necessity via Documentation
You must use your paperwork wisely to establish a medical necessity for the rendered gait training. So, your documentation for CPT code 97116 must include:
- The disease or injury that caused an impaired gait.
- The functional goal of the service.
- The level of assistance provided and the tasks practiced.
- How therapy addressed the patient’s deficit.
- The start and end times (minutes per activity and total minutes).
- The patient’s progress.
Follow Payers’ Specific Policies
Our last advice is to stay updated with the ever-changing policies of insurance payers and take prompt action to comply with them. Different payers may have unique requirements. So you must refer to the billing manuals specific to each payer for coding guidelines and documentation prerequisites. Furthermore, you must be mindful of any limitations concerning the number of units or frequency of billing for gait training.
Final Word
CPT code 97116 represents gait training for 15 minutes. Hopefully, the explanation of this code must have become clearer with the detailed scenarios we discussed above. However, exercise caution when using modifiers because you are required to submit supporting documentation for the modifier’s use and to demonstrate the procedure’s medical necessity.
We strongly advise you to use professional physical therapy billing services if this article did not resolve your issues.
