2025 CPT code 97116
(Active) Effective Date: N/A Physical Medicine and Rehabilitation - Therapeutic Procedures Feed
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing).
This code does not accept modifier 51.
Gait training is medically necessary when a patient's walking ability is impaired due to a medical condition or injury and there is a reasonable expectation of improvement with skilled therapeutic intervention.
The physician or therapist is responsible for demonstrating exercises, instructing gait sequences, ensuring patient safety, and providing direct one-on-one contact throughout the 15-minute session.
In simple words: Gait training helps people improve their walking ability. A therapist or doctor works one-on-one with the patient, teaching them exercises and activities to improve their walking and balance, including how to climb stairs. The therapist shows the patient how to do the exercises, keeps them safe, and stays with them during the session.
This code represents gait training, a therapeutic procedure that focuses on improving a patient's ambulation (walking) and functional mobility. It involves direct, one-on-one patient contact with the physician or other qualified healthcare professional (e.g., therapist) who guides the patient through specific functional activities and exercises, including stair climbing.The provider demonstrates the exercises, provides safety instructions, and remains in direct contact with the patient during the therapy session. The exercises target movement activities with instructed gait sequences and may involve assistive devices or weights as appropriate.
Example 1: A patient post-stroke experiences difficulty walking and requires gait training to improve balance and coordination. The therapist uses 97116 to bill for the 15-minute sessions., A patient with multiple sclerosis has impaired mobility. Gait training is prescribed to enhance their functional ambulation using assistive devices. Code 97116 is used for billing., A patient recovering from a lower limb injury undergoes gait training to regain normal walking patterns and improve strength.97116 is used for the therapy sessions.
Documentation should include the medical necessity for gait training, the patient's diagnosis, specific exercises and activities performed, the duration of each session (15 minutes), and the patient's response to the therapy. Any assistive devices or weights utilized should also be noted.
- Specialties:Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, and other specialties managing conditions affecting gait and mobility.
- Place of Service:Outpatient Hospital, Inpatient Hospital, Skilled Nursing Facility, Rehabilitation Facility, Office, Home, and other settings where gait training can be provided.