Question: We frequently teach our patients how to use crutches when they are recovering from conditions such as hip replacements, stroke, foot surgery, knee problems, etc. Often, this takes longer than expected because the patient may have a weak upper body, or is not used to bearing that type of weight. We have been billing a low-level office visit code (99211) for this, but can we bill one of the modality codes (such as therapeutic exercise)?
Illinois Subscriber
Answer: If an RN is teaching the patients, you should continue using 99211. If another member of your staff, such as a physiatrist or therapist, is performing the training, you can bill 97116 (gait training). (Code 97116 reimburses at an average of $5 to $10 more.) Upper-body strengthening to help the patient acclimate to the crutches should be coded with the therapeutic procedure code (97110).
Any services that a therapist provides should be part of the treatment plan that is approved and overseen by the physician.