Eli's Rehab Report

Published on Mon Apr 17, 2006 PDF

Question: Our office manager thinks our therapist's gait training documentation refers to "maintenance therapy" and therefore isn't payable, but the therapist disagrees. How can we determine the difference between maintenance and non-maintenance therapy?


Tennessee Subscriber


Answer: If your patient has already met all of her rehabilitation goals and no longer shows any progress, your carrier will probably consider the gait training "maintenance" and refuse to pay for CPT 97116 claims (Therapeutic procedure, one or more areas, each 15 minutes; gait training [includes stair climbing]).

According to the policy of Blue Cross and Blue Shield of Tennessee, gait training is a skilled service (and therefore may be payable) "if the patient's ability to walk has been impaired and when training can be expected to significantly improve the patient's ability to walk."

The carrier considers gait training nonskilled "after the gait has been taught and the goal is merely walking to improve distance or endurance."

Some payers will reimburse maintenance for periodic evaluations to determine whether the patient has responded well to treatment, but these services are payable only on a case-by-case basis.