CATEGORY
Physical and Rehabilitation Therapy procedures
CODE TYPE
Timed-based code
Billed in 15 minutes increment
ADD-ON CODE
No add-on code
CPT 97116 is used when the qualified healthcare provider trains the patient in specific functional activities designed to improve patient ambulation.
This CPT is not considered medical necessary when the goal of the treatment is to increase muscular strength and endurance.
Gait training is not considered medically necessary, even if the patient’s gait ability cannot be expected to improve as a result of gait training.
Types of Exercises that are included:
- Parallel bar walking
- Walking on a treadmill
- Sits-and-stands
- Stepping over objects
- Stairs climbing
- Leg lifts
- Single leg stance
CODING GUIDELINES
- One-on-one therapy code
- Billed in 15-minutes increment
- Require a therapy modifier (GP, GN, GO, CO, CQ)
- CMS 8-minute and AMA rule of Eights are applied
CMS 8-Minute Rule:
A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97116 to be billed.
| Units | Number of Minutes |
|---|---|
| 1 unit | ≥ 08 minutes through 22 minutes |
| 2 units | ≥ 23 minutes through 37 minutes |
| 3 units | ≥ 38 minutes through 52 minutes |
| 4 units | ≥ 53 minutes through 67 minutes |
| 5 units | ≥ 68 minutes through 82 minutes |
| 6 units | ≥ 83 minutes through 97 minutes |
| 7 units | ≥ 98 minutes through 112 minutes |
| 8 units | ≥ 113 minutes through 127 minutes |
The pattern remains the same for treatment times of more than 2 hours.
AMA Rule of Eights:
“AMA guidelines state that incremental intervals of treatment performed on the same session may be added together when determining total time in direct contact of a qualified healthcare provider with the patient is necessary. Each unique timed service is counted separately instead of combining the time from multiple units”
Physical Therapy Modifiers
Below mentioned modifiers are used when services are provided for the respective plan of care:
| MODIFIERS | PLAN OF CARE |
|---|---|
| GP | Outpatient Physical Therapy |
| GO | Outpatient Occupational Therapy |
| GN | Outpatient Speech-Language Pathology |
| CQ | Outpatient Physical Therapy by a Physical Therapist Assistant (completely or partially) |
| CO | Outpatient Occupational Therapy by an Occupational Therapy Assistant (completely or partially) |
TOTAL NO. OF BILLABLE UNITS
04 units are allowed per date of service by CMS but more units can be billed if justified by medical notes.
MEDICAL NECESSITY
It may be considered medically necessary if one of the following conditions is present and documented:
- Any disease\condition or injury (spinal or brain) which results in impaired gait
- Patient has a chronic debilitating disease and cannot safely ambulate
- Patient cannot ambulate without use of assistive or adaptive equipment
- Requires education in safe transfer technique from bed to chair etc. in addition to
gait training
REIMBURSEMENT GUIDELINES
For reimbursement following elements must be documented in the Physical Therapy Notes:
- Physical Therapy diagnosis such as impaired gait or inability to safely transfer or climb stairs to justify medical necessity.
- Total direct time spent by the provider with patient.
