Eli's Rehab Report

Reader Question:

Gait Training

Published on Wed Aug 01, 2001

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Question: Our therapist did not note the amount of time she spent with a patient, but on her encounter form she entered "97116 x 2." None of the chart notes reflect the time. Can I code this directly from her encounter form, or would that not be correct coding?

Colorado Subscriber

Answer: It would not be correct coding to copy the therapist's suggestion if documentation does not support the codes. If you billed two units of 97116 (gait training) and your records were audited, the documentation would not warrant the codes that you billed, and your practice would be at fault.

You should ask the therapist to attach an addendum to the chart so that the records accurately represent what was performed. For instance, if she had the patient practice stair climbing for 15 minutes and then had the patient walk a treadmill for an additional 15 minutes, she should document that so you can bill for both units without any problems (97116 is billed in units of 15 minutes).

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