CPT code 97116 describes gait training, a type of physical therapy that helps patients improve their ability to walk and move.
What Is CPT Code 97116?
CPT 97116 describes a therapeutic procedure called gait training, a type of physical therapy designed to help patients with movement problems related to walking.
The procedure involves the patient performing exercises to improve their gait, such as walking, climbing stairs, and ambulating with or without assistive devices.
The therapist provides instruction and safety guidelines and may also use weights to increase the exercises’ challenge for patients who can tolerate it.
Gait training is typically used to help patients who have difficulty walking due to health conditions or injuries and is often provided by physical therapists.
The CPT book describes CPT code 97116 as: “Therapeutic procedure, one or more areas, every 15 minutes; gait training (includes stair climbing).”
The physician demonstrates the exercises to the patient. The exercises are related to movement activities with instructed gait sequences.
The patient ambulates. Climbs stairs (with or without assistive devices), forward walks, backward walks sideways with or without dowels, straightens legs while sitting on a chair, etc.
Sometimes a few weights are attached to the ankle in patients strong enough to tolerate the added challenge.
The physician provides safety instructions and remains in direct contact with the patient during therapy.
Gait training is a type of physical therapy provided by physical therapists, to patients who have problems with normal walking due to a health condition (intermittent claudication, for example) or as the result of an injury, amputation, or other surgeries (mainly in the lower limbs), etc.
How To Use CPT 97116
CPT code 97116 is not medically reasonable and necessary when the patient’s walking ability is not expected to improve.
Repetitive walk–strengthening exercises for feeble or unstable patients or to increase endurance do not require provider supervision and will be denied as not reasonable and necessary.
You may report CPT 96000, CPT 96001, CPT 96002, or CPT 96003 for comprehensive gait and motion analysis procedures.