Neurology & Pain Management Coding Alert

Question: My neurologist has been billing 97116 for gait training with no problem until earlier this year. Medicare now denies the claims. Is there another code we could use instead of 97116? 

Vermont Subscriber 

Answer: Medicare could be denying the claims for a variety of reasons that we can’t confirm without additional information. Here are some possibilities that you should double check before filing your next claim. 

• Diagnosis: The denial could be related to a diagnosis code that doesn’t meet medical necessity guidelines. For example, many Medicare LCDs state that, “Gait training is not considered medically reasonable and necessary when the patient’s walking ability is not expected to improve. This procedure is not considered medically necessary when the goal is to increase the patient’s strength and endurance.”
• Modifiers: Missing modifiers could also be leading to the denials, whether it’s the required GP modifier indicating that the service was provided under a physical therapy plan of care or modifiers required by coding edits because of bundled procedures (depending upon what other services your neurologist provided during the same encounter).
• Codes: Your claim might be missing the Medicare required functional reporting required HCPCS “G” codes and corresponding modifier for the percentage of impairment limitation.
• Timing: Some payers stipulate how often a patient can have gait training services. Ask whether the denial could be because of the training frequency. 

Another point: The procedure represented by 97116 (Therapeutic procedure, 1 or more areas, each 15 minutes; gait training [includes stair climbing]) is not medically reasonable and necessary when the patient’s walking ability is not expected to improve. Repetitive walk–strengthening exercise for feeble or unstable patients or to increase the patient’s endurance do not require provider supervision and will be denied as not reasonable and necessary.