In high-performing rehab organizations, every CPT code represents more than just a billing line—it’s a lever for consistency, compliance, and clinical excellence. Gait training (CPT code 97116) is no exception.
Often prescribed for patients recovering from neurological events, orthopedic surgery, or balance disorders, 97116 plays a vital role in functional mobility and safe ambulation. But at scale, inconsistent use of this code can lead to revenue leakage, audit risk, and variable care delivery across sites and teams.
For enterprise rehab groups managing dozens—or even hundreds—of clinicians, the challenge isn’t just delivering effective gait training. It’s ensuring that every instance is documented properly, billed compliantly, and tracked for measurable outcomes.
The Basics: What is CPT Code 97116?
CPT code 97116 is defined as, “Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing).” It is used to document and bill for gait training services such as walking with or without assistive devices to prevent falls and improve mobility.
The code describes a specific type of physical and occupational therapy intervention that requires direct one-on-one contact with the patient. The need for gait training must be considered medically necessary and relate to the goals of the patient’s treatment plan.
This code is used when delivering therapy focused on improving a patient’s ability to walk safely after an injury or illness, such as a stroke or spinal cord injury.
What Does CPT® Code 97116 Cover?
Gait training therapy encompasses a variety of interventions designed to help OT or PT patients walk more safely and efficiently. Therapists tailor these treatments to each patient’s specific needs, which may include:
- Re-educating walking mechanics. Improving stride length, weight distribution, and correcting compensatory movements like improper foot placement.
Balance and coordination exercises. Activities such as weight-shifting or single-leg stance drills to enhance stability.
Sit-to-stand training. Practicing this essential transition to build control, strength, and reduce fall risk.
Assistive device training. Teaching proper use of canes, walkers, or other devices to increase independence and mobility.
Navigating obstacles and varied terrain. Preparing patients to walk safely on curbs, stairs, or uneven surfaces through real-world or simulated practice.
It’s important to note that CPT code 97116 is not intended for general strengthening or conditioning exercises. If the primary goal of treatment is to build muscle strength, improve endurance, or enhance flexibility, other codes may be more appropriate. For example, CPT code 97110—used for therapeutic exercises to improve strength, range of motion, and flexibility—would typically apply in those cases.
CPT Code 97116 Billing and Coding Guidelines
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Time-Based Billing Rules
CMS 8-Minute Rule:
Primarily used in Medicare billing, this rule stipulates that clinicians must provide at least 8 minutes of direct, face-to-face therapy to bill a single unit of 97116.American Medical Association (AMA) “Rule of Eights”:
Used by many commercial payers, this rule also allows 1 unit per 8–22 minutes of service, with each additional 15-minute increment qualifying for another unit after reaching the threshold.
Required Therapy Modifiers
When billing CPT 97116, always include the appropriate therapy modifier:
GP – Physical therapy services
GO – Occupational therapy services
GN – Speech-language pathology services
CQ – Services provided in whole or in part by a PTA
CO – Services provided in whole or in part by an OTA
💯 Enterprise Insight
In multi-site practices, inconsistent use of therapy modifiers can lead to reimbursement delays or denials. Automating modifier logic through your EMR or billing software—like Raintree—helps maintain compliance at scale.
Documentation Requirements
To bill 97116 compliantly, documentation must show how gait training directly supports the patient’s functional goals. The intervention is typically considered medically necessary when at least one of the following conditions is met and clearly documented:
The patient has a neurological, orthopedic, or systemic condition impairing gait (e.g., stroke, Parkinson’s, spinal cord injury).
The patient is unable to ambulate safely without supervision or assistive equipment.
The patient requires training in transfer techniques, such as moving from bed to chair or standing from a seated position.
The patient has a chronic or progressive disease impacting mobility or fall risk.
Reimbursement and Compliance at Scale
In large rehab organizations, the ripple effect of inconsistent coding can be significant. When CPT code 97116 is miscoded—even occasionally—those errors can scale into lost revenue, denials, or compliance risk across hundreds or thousands of visits.
In summary, to ensure proper reimbursement for gait training, therapists must:
Deliver at least 8 minutes of direct, one-on-one gait training per unit billed (per CMS and AMA time rules).
Clearly document medical necessity, linking gait training to functional impairments such as neurologic deficits, post-surgical mobility issues, or high fall risk.
Accurately apply required modifiers (e.g., GP, CQ) and record minutes per payer guidelines.
CPT 97116 is reimbursable across multiple settings—including outpatient, inpatient rehab, SNFs, and home health—but only when documentation clearly ties the intervention to patient-specific treatment goals.
For enterprise practices, the key is to standardize documentation workflows and coding protocols across locations to minimize variability, reduce audit exposure, and protect revenue.
Smarter Coding Starts with Smarter Systems
At enterprise scale, consistent use of CPT codes like 97116 isn’t just about compliance—it’s about protecting revenue, reducing rework, and delivering consistent care across every location.
Raintree’s enterprise-grade EMR, leading billing software, and ScribeIQ™ (our AI scribe for PT and rehabilitation) work together to help therapy organizations code accurately, bill efficiently, and document with confidence.
Ready to scale smarter? 👉 See Raintree in action and discover how we help rehab therapy leaders streamline operations from documentation to reimbursement.
Frequently Asked Questions
Who Uses CPT 97116 and how is it billed?
Qualified occupational therapists and physical therapists use this CPT code for gait training techniques.
Can CPT code 97116 and 97530 be billed together?
Yes—but only use this code combination when the services are distinct and separately identifiable. CPT 97116 (gait training) and CPT 97530 (therapeutic activities) can be billed during the same session if:
Each service addresses a different therapeutic goal
Documentation clearly supports separate interventions
Time spent on each is tracked and reported independently
Does CPT code 97116 need a modifier?
Yes. CPT code 97116 requires appropriate therapy modifiers to indicate the type of service and who provided it. For example, GP is used for physical therapy services, and CQ is required when services are delivered in whole or in part by a physical therapist assistant. These modifiers are especially important for Medicare billing and must align with the therapist’s credentials and setting.
