How To Use CPT Code 97116

CPT 97116 describes a therapeutic procedure that involves gait training for patients. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 97116?

CPT 97116 can be used to describe a therapeutic procedure that focuses on gait training. This procedure is designed to help patients improve their walking ability and address any issues they may have with normal walking due to a health condition or injury. Gait training may involve various exercises and activities to assist patients in walking comfortably and without strain.

2. Official Description

The official description of CPT code 97116 is: ‘Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing).’ This code is used to report the time spent by a healthcare provider in instructing and supervising the patient during gait training sessions.

3. Procedure

1. The healthcare provider demonstrates various exercises and movement activities related to gait sequences.
2. The patient is instructed to ambulate, climb stairs (with or without assistive devices), walk forward, walk backward, walk sideways, and straighten legs while sitting on a chair.
3. Weights may be attached to the patient’s ankles to provide an added challenge, if appropriate.
4. The healthcare provider remains in direct contact with the patient during the therapy to ensure safety and provide necessary instructions.

4. Qualifying circumstances

CPT 97116 is appropriate for patients who require gait training to improve their walking ability. This may include individuals with health conditions such as intermittent claudication or those recovering from injuries, surgeries, or amputations that affect their ability to walk normally. The therapy is typically provided by physical therapists who specialize in gait training.

5. When to use CPT code 97116

CPT code 97116 should be used when a healthcare provider performs gait training for a patient. It is important to ensure that the patient’s walking ability is expected to improve with the therapy. Repetitive walk-strengthening exercises for feeble or unstable patients or exercises solely aimed at increasing endurance may not require provider supervision and may not be considered medically reasonable and necessary.

6. Documentation requirements

To support a claim for CPT 97116, the healthcare provider must document the following information:

• Patient’s diagnosis or condition requiring gait training
• Specific exercises and activities performed during the therapy
• Date and duration of each therapy session
• Progress made by the patient
• Any additional instructions or recommendations provided
• Signature of the healthcare provider

7. Billing guidelines

When billing for CPT 97116, ensure that the therapy is provided by a qualified healthcare provider, such as a physical therapist. The therapy session should be properly documented and meet the requirements for medical necessity. It is important to review payer-specific guidelines and policies to ensure accurate billing and reimbursement.

8. Historical information

CPT 97116 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2010, with an updated description: ‘Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing).’ No further updates have been made to the code since then.

9. Examples

1. A physical therapist providing gait training to a patient recovering from knee surgery.
2. A healthcare provider instructing a patient with intermittent claudication on proper walking techniques and stair climbing.
3. A physical therapist assisting a patient with an amputation in learning to use a prosthetic limb and regain walking ability.
4. A healthcare provider guiding a patient with a neurological condition in improving their balance and coordination during walking.
5. A physical therapist helping a patient with a hip injury regain strength and stability while walking.
6. A healthcare provider providing gait training to a patient with a chronic condition that affects their walking ability.
7. A physical therapist assisting an elderly patient in improving their walking speed and endurance.
8. A healthcare provider instructing a patient with a foot injury on proper walking mechanics and weight distribution.
9. A physical therapist guiding a patient with a spinal cord injury in learning to walk with assistive devices.
10. A healthcare provider providing gait training to a patient with a musculoskeletal condition that affects their walking ability.