CPT code 97116

97116 CPT code for Gait Training, describes an intervention that trains a client in specific functional activities to improve ambulation (walking) and functional mobility. This intervention must be provided by a qualified clinician and considered medically necessary.

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Occupational therapists often collaborate with physical therapists to incorporate functional mobility into an Activities for Daily Living routine to provide gait training to complement an ADL routine.

Because functional mobility is considered an activity of daily living (ADL), occupational therapists often intertwine functional mobility with other ADLs to move about their home for necessary ADLs. When a client says their goal for therapy is “to walk”; an occupational therapist will ask “where and why?” to incorporate occupation into a client’s functional mobility goals. This article will look at considerations when applying this procedure code to therapy sessions to improve your accuracy for billing and reimbursement.

What is 97116 CPT code?

The American Medical Association defines 97116 CPT code as a therapeutic procedure to one or more areas every 15 minutes. For gait training, that includes stair climbing. Occupational therapists must consider the context for the client when addressing underlying performance limitations to implement an effective and meaningful intervention.

Types of procedures covered by 97116 CPT code

• Transfers for ADLs in combination with functional mobility such as getting out of bed and walking to a closet to retrieve clothes

• Walking in a store to shop for groceries

• Carrying supplies to the bathroom for bathing

• Walking while using a vacuum to clean the floor

• Training a client to carry food from kitchen to dining table for serving and eating

Medical necessity and coverage criteria for 97116 CPT code

As with all coding and billing, documentation needs to justify how intervention will help the client meet their goals and specify what kind of assistance is required by the therapist and why intervention was administered.

Additional considerations for medical necessity include:

• Centers for Medicare and Medicaid Services (CMS) requires that ICD-10-CM diagnosis code G82.20, Paraplegia, unspecified Nontraumatic acute complete paraplegia must be present and documented for reimbursement.

• Procedure code 97116 is a timed code that must be used for one-on-one, direct service provided by a qualified therapist or physician.

• Intervention must be directly related to specific goals listed in the treatment plan with a clear link to how intervention will improve performance and meet goals documented.

• If a client needs to learn how to use an assistive device for functional mobility to prevent falls.

• Procedure code 97116 is NOT considered medically necessary when the goal of treatment is to increase muscle strength, endurance or if functional mobility ability is not expected to improve after intervention. It must relate to achieving or improving functional mobility.

Documentation requirements to bill CPT code 97116

Per CMS guidelines, the following requirements must be present in your documentation for reimbursement.

• Ensure the prior functional level of function and level of assistance required is documented to further establish the client’s potential and rehabilitation prognosis.

• Justify why gait training is necessary for the client to meet their treatment plan goals.

• Describe the client’s impairments and functional limitations requiring skilled intervention and strengths that support their rehab potential.

• Describe the clinical skill required, how much and what type of assistance is required for functional mobility.

• Document both Timed Code Treatment Minutes and Total Treatment Time to justify the units billed.

• Identify each specific skilled intervention modality provided to justify codes selected.

• Specific gait training techniques used along with instructions given to the client, level and type of assistance needed, and the client’s response to the intervention, to demonstrate clinical skill required.

• Supportive documentation required every 10 visits to include support for continued gait training beyond 12-18 visits within a 4–6-week period, reporting continued progress to be achieved and to avoid services appearing repetitive.

• Continue documenting objective outcome measurements for routine assessments to record balance and gait distance, if an assistive device is used, amount of assistance required, gait deviations limiting performance, gait limitations being addressed, if client uses an orthotic or prosthesis, and if the client requires verbal cueing with reasons why.

• Document continued limiting contextual factors including pain, balance deficits, gait deficits, environmental barriers, or safety concerns that require continued therapy to address.

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97116 CPT code and occupational therapy

Occupational therapy services covered by 97116 CPT code include procedures to improve a client’s overall safety and independence during functional mobility when carrying out their daily routine. These include training a client to use assistive devices to move about their home for ADLs, combining walking and transfers when completing a bathing routine, or teaching a client how to walk and carry a plate of food when preparing to eat at a table.

Treatment modalities are generally billed for separate time outside of direct treatment time except for functional electrical stimulation that is applied and used in addition to a skilled therapist working on gait training. CMS limits coverage of FES with 97116 CPT code to clients with a documented spinal cord injury for walking, covering 32 visits, and provided by a physical therapist to help determine if FES will improve long-term outcomes and performance.

97116 CPT code fits into occupational therapy treatment plans as therapists use functional mobility to help connect a client’s meaningful occupations into a daily routine that includes walking to, from, and between activities. There are occasions when an occupational therapist works alone, but generally, an occupational therapist will work as part of a team that will include a physical therapist and physician when incorporating gait training into a holistic treatment plan.

Maximizing reimbursement for 97116 CPT code

Common reimbursement issues include charging for gait training when it is not necessary for client functional performance such as when a walking ability is not expected to improve or when used for strengthening if a client already walks at a supervision level. 97116 CPT code is for gait training for clients whose functional mobility may improve as an outcome of the intervention.

Additionally, if a client requires two therapists to complete gait training every 15 minutes of intervention still counts as 1 unit, meaning both treating therapists will split the billable time or only one therapist will bill for gait training.

Coding and billing tips for 97116 CPT code

• Bill in 15-minute increments, following the 8-minute rule. A minimum of 8 minutes of direct, one-to-one contact with the client must be provided for a single unit of 97116 to be billed.

• This code may require a therapy modifier to distinguish who provided the service.

• Four units maximum of 97116 CPT code are allowed per treatment session per CMS but more units may be allowed if additional units are clearly justified in medical documentation.

• Documentation should clearly illustrate why distinct intervention for gait training was administered in the same session as home management, orthotic training or prosthetic fitting and training.

Key documentation elements for reimbursement success

Ensure that you have all required and supportive documentation listed in your treatment notes with the signature of the treating provider. Review your insurance payor provider manuals for additional requirements when billing for procedure code 97116. CMS has a public resource, Billing and Coding: Out-client Physical and Occupational Therapy Services for all necessary guidelines when using this code in your treatment sessions.

97116 CPT code and compliance

For compliance regulations, treatment for 97116 CPT code should be provided by a qualified provider during direct, one-to-one treatment for one unit per 15 minutes of treatment. Potential compliance risks lie in not having accurate minutes recorded in your medical documentation and not documenting a clear relationship for how gait training will help your client achieve goals in their treatment plan.

Strategies to ensure compliance for using the gait training procedure in your sessions include reviewing the tips listed above and reviewing billing and coding guidelines in your respective payor provider manuals and the Centers for Medicare and Medicaid Services (CMS) rehabilitation resources.

To summarize, procedure code 97116 is for gait training when a therapist or physician trains a client in specific functional activities to improve ambulation (walking) and functional mobility. Occupational therapists often work alongside physical therapists when incorporating gait training into a client’s ADL and IADL routine to improve overall independence and safety to complete a daily routine.

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How EHR and practice management software can save occupational therapists time on insurance billing

EHR with integrated billing software and a clearing house, such as TheraPlatform, offers OTs significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching.

What are automation and batching?

• Automation refers to setting up software to perform tasks with limited human interaction.

• Batching or performing administrative tasks in blocks of time at once allows you to perform a task from a single entry point with less clicking.

Which billing and medical claim tasks can be automated and batched through billing software?

• Invoices: Create multiple invoices for multiple clients with a click or two of a button or set up auto-invoice creation, and the software will automatically create invoices for you at the preferred time. You can even have the system automatically send invoices to your clients.

• Credit card processing: Charge multiple clients with a click of a button or set up auto credit card billing, and the billing software will automatically charge the card (easier than swiping!)

• Email payment reminders: Never manually send another reminder email for payment again, or skip this altogether by enabling auto credit card charges.

• Automated claim creation and submission: Batch multiple claims with one button click or turn auto claim creation and submission on.

• Live claim validation: The system reviews each claim to catch any human errors before submission, saving you time and reducing rejected claims.

• Automated payment posting: Streamline posting procedures for paid medical claims with ERA. When insurance offers ERA, all their payments will post automatically on TheraPlatform's EHR.
• Tracking: Track payment and profits, including aging invoices, overdue invoices, transactions, billed services, service providers.

Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save occupational therapy providers time when it comes to insurance billing for therapists.

Resources

TheraPlatform is an all-in-one EHR, practice management, and teletherapy software built for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports different industries and sizes of practices, including occupational therapists in group and solo practices.

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• Insurance billing 101
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