CPT Code 97116: Description & Reimbursement Guidelines

Gait issues are a big problem in the USA. Every year, millions of people are affected by it, making it harder for them to perform simple everyday actions like walking and maintaining balance, especially after recovering from an injury. Physical therapists help these patients relearn walking patterns. However, billing gait training exercises for reimbursement is not easy.

One code that is frequently used to bill such physical therapy sessions is CPT code 97116. We have created this guide to simplify this code for you. 

We will explain in detail what this code entails, how to use it, and some real-world scenarios that will help you understand how the code is applied in clinical settings. So, let’s start. 

CPT Code 97116 – Description

CPT code 97116 is defined as:

“Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing).”

This doesn’t explain much, so here’s a more detailed version:

“A timed therapeutic procedure (15 minutes per unit) in which a qualified physical therapist or licensed practitioner provides individualized gait training to address walking impairments, assistive device use, stair negotiation, surface transitions, and functional ambulation skills.”

As evident from the description, 97116 is a physical therapy code. It is used to bill a one-on-one gait training session. Also, 97116 is a time-based code, so it cannot be applied to group services. 

The time rules are based on the Centers for Medicare & Medicaid Services (CMS)’s 8-minute rule. This means that even if the session lasts 8 minutes, it will still count as a valid session and 1 unit of 97116 is billable. 

Here is a more detailed breakdown of the 8-minute rule:

Time Spent	Units Billable
8 – 22 minutes	1 unit
23 – 37 minutes	2 units
38 – 52 minutes	3 units
53 – 67 minutes	4 units

An important point to note here is that CPT code 97116  is not considered medically necessary when the treatment goal is solely to increase muscle strength, endurance, or general fitness, and when functional mobility improvement is not an expected outcome. The code applies specifically when a skilled therapist is needed to address a documented gait deficit.

Scenarios Where CPT Code 97116 is Applicable

Here are a couple of real-world scenarios in which CPT code 97116 can be used:

Post-Stroke Gait Rehabilitation

For our first scenario, suppose that a patient comes to a physical therapy center. The patient has hemiplegia on the left side of his body, caused by a stroke. As a treatment, the physician has prescribed gait training. So, he comes to the center for his gait training. 

During the session, the physical therapist provides gait training that is focused on weight shifting, heel-to-toe sequencing, and surface-specific ambulation. The entire exercise session lasts around 15 minutes.

Since all the requirements we discussed in the previous sections are met, the billing department can bill one unit of CPT code 97116 for reimbursement. 

Post-Orthopedic Surgery Recovery

Now imagine that a man recently underwent a total knee arthroplasty. Due to this, he can’t walk properly without someone supervising him. To recover from this, he needs training. So, the physician refers him to a physical therapist for proper weight-bearing sequencing, walker use, and stair negotiation.

He visits the therapist. The session starts, and the therapist provides him with some instructions about gait mechanics and assistive device adjustment. The therapist also provides gait training that focuses on step length and balance during ambulation and lasts 25 minutes. 

Hence, the billing department can bill 2 units of CPT code 97116.

Applicable Modifiers for CPT Code 97116

The following modifiers are frequently used with CPT code 97116:

Modifier	Description	Application
GP	Services delivered under an outpatient physical therapy plan of care.	Must be applied to all physical therapy services.
CQ	When a physical therapy assistant provides >10% of the service.	Service is reimbursed at 85% of the standard physical therapist rate.
59	Distinct/separate service	When 97116 is used with another therapy code that might normally be bundled (like manual therapy).
KX	Medical necessity exception	When exceeding therapy threshold amounts under Medicare, while documenting continued medical necessity.

CPT Code 97116 – Reimbursement Guidelines

Here are some additional guidelines that you should follow to get proper reimbursement for CPT code 97116 claims:

Always Provide Detailed Documentation

Documentation is the most important part of any claim. You can use the correct codes and modifiers all you want, but if your documentation has gaps, your claims will be rejected. For 97116, here’s what is important to provide:

• Document the patient’s baseline mobility status and level of assistance required. This should be done before providing any treatment.
• Clearly describe the specific gait impairment being treated.
• Explain why gait training requires a licensed physical therapist and cannot be accomplished through a non-skilled caregiver.
• Record the type of device used.
• Include objective gait measures such as gait speed, distance walked, or standardized functional assessments.
• Accurately measure the session’s start and stop times. 

Provide a Valid ICD-10 Diagnosis Code

You cannot use CPT code 97116 for every patient who has gait issues. For this code to be valid, it must be supported by a valid ICD-10 diagnosis code. Some frequently used diagnosis codes with 97116 are:

• G12.23
• G82.20
• I63.9 
• R26.81 

Check the Medicare Reimbursement Rate

Reimbursement for CPT code 97116 varies. Every insurance payer has its reimbursement rate, which in turn varies for each locality. However, Medicare’s national average reimbursement amount for CPT code 97116 is $29.06 for both non-facility and facility settings. 

You can check the exact amount for your Medicare Administrative Contractor (MAC) address via the PFS Lookup Tool. 

Wrapping Up

CPT code 97116 is one of the most important physical therapy codes. It is used to bill gait training sessions. Each session is billed in units, which are calculated via the 8-minute rule. However, billing 97116 can be tricky, as it has a lot of requirements that must be met for it to be valid. 

If you are facing claim denials even after following all the guidelines that we just discussed, consider getting our physical therapy billing services. Our billing experts have decades of experience handling billing issues and denials.

Frequently Asked Questions