CPT Code 97116: A Guide for Therapists

CMS 2026 Update — CPT 97116

CMS guidance for CPT 97116 (Gait training) remains unchanged for CY2026; emphasis remains on documenting specific gait deficits, assistive devices used, and measurable progress.

What is CPT 97116?

CPT 97116 represents Gait Training — a therapeutic procedure aimed at improving a patient's ability to walk. This includes activities such as walking on different surfaces, negotiating obstacles, and using assistive devices.

Typical uses: Rehabilitation after surgery, injury recovery, and improvement of balance and coordination.

In short: CPT 97116 = Gait Training.

When to Use CPT 97116 (and When Not To)

Use 97116 for patients requiring gait training to improve mobility and balance.

• Report when gait training is medically necessary for rehabilitation.
• Ensure documentation supports the need for skilled intervention.

Do not use for general exercise or non-skilled walking activities.

Clinical Examples

• Post-stroke rehabilitation → 97116
• General physical therapy exercises → 97110

97116 vs 97110 (Quick Comparison)

2025 Reimbursement Rates (Representative)

Documentation Guidelines (CMS & MIPS 2025 Compliant)

Thorough documentation demonstrates medical necessity, skilled care, and functional intent. Include:

1. Functional goal (e.g., “Patient will improve gait stability to reduce fall risk”).
2. Activity description — explicit tasks practiced, environment, and level of assistance.
3. Clinical rationale — why this activity addresses the patient’s deficit.
4. Time documentation — minutes per activity and total minutes (apply the 8-minute rule for units).
5. Patient response — tolerance, cues required, measurable progress.

Sample SOAP Note (De-identified)

S: Patient reports feeling more stable when walking with a cane.
O: Observed patient walking 50 feet with moderate assistance, using a quad cane.
A: Patient demonstrates improved balance but requires further gait training to achieve independence.
P: Continue gait training 3x/week focusing on uneven surfaces and obstacle negotiation.
  

Modifiers & Coding Tips

Claim tip: Ensure documentation supports the use of modifiers to avoid denials.

Common Denials & How to Prevent Them

1. Insufficient documentation — Fix: Ensure all elements of skilled care are documented.
2. Incorrect modifier usage — Fix: Verify the necessity and correct application of modifiers.
3. Lack of medical necessity — Fix: Clearly document the clinical need for gait training.

Audit trigger: Frequent use of modifier -59 without clear justification.

Region & Local Payer Notes

In Michigan, ensure compliance with WPS Medicare guidelines for CPT 97116. Local payer policies may vary, so verify specific requirements with each insurer.

FAQs

What is included in gait training?

Gait training involves interventions to improve walking capacity, safety, and independence, including balance and assistive device training.

How to document use of assistive devices?

Record device type, fitting, adjustments, and training provided during the session.

Are objective measures important?

Yes — include gait speed, distance, or standardized measures to show progress.

Can gait training be billed with therapeutic exercise?

Yes, when services are separate and distinct with documented skilled actions for each.

What causes denials for gait training?

Common denial reasons include vague notes, lack of measurable goals, and missing device documentation.

How to plan for long-term gait therapy?

Set short-term, measurable goals and periodically re-evaluate to support ongoing services.