Vol. 15 Issue 24
Subacute and Long-term Care
Documenting Gait Training as a Skilled Service
PTs and PTAs in long-term care spend much of their time providing gait training, yet their documentation may fail to show that the service required the skills and judgment of a licensed professional. Writing "Patient ambulated 100 feet with a wheeled walker and minimum assist" does not indicate that a skilled service was provided.
At a recent state physical therapy conference, consultant Angela Phillips said that gait training, which is billed using the CPT code 97116, does not include ambulation for endurance. Ambulation for distance or endurance should be billed as therapeutic exercise using the CPT code 97110, since therapeutic exercise includes procedures to improve strength, endurance, range of motion and flexibility.1
Services provided by a rehab aide to accompany a patient who practices walking can't be billed as gait training, since only PTs and PTAs have the knowledge and skills to assess and correct gait. Walking or ambulation with an aide can be billed as therapeutic exercise if properly supervised.
Gait Training vs. Ambulation
What is the difference between gait training and ambulation? Gait refers to the manner of walking, characterized by rhythm, cadence, step, stride and speed, whereas ambulation simply indicates the ability to walk. Coffman said that gait training requires assessment of the manner of walking and instruction to improve or correct the manner of walking.2 She cites Taber's Cyclopedic Medical Dictionary, which gives descriptions of gait as ataxic, cerebellar, double step, drag-to, equine, festinating, gluteal, hemiplegic, scissor, spastic, steppage, swing-through, swing-to, three-point, two-point and waddling.
The Centers for Medicare & Medicaid Services (CMS) gives clear guidance to therapists in documenting gait training in order to meet Medicare regulations. In general, PTs and PTAs must provide services that cannot safely or effectively be performed by nonlicensed personnel, and there must be an expectation that the patient's condition will improve significantly in a reasonable period of time.
A CMS article states: "Thorough medical record documentation is critical in differentiating between skilled gait training versus assisted walking. The documentation must support the need for skilled gait training to restore functional abilities (or to design and establish a safe maintenance program) which can reasonably be expected to improve the patient's ability to walk, or the patient's gait deviation, current functional abilities and limitations, and/or safety dependence during gait. Documentation should identify the gait problem being treated, e.g., to correct a balance/coordination and safety problem or a specific gait deviation, such as a Trendelenberg gait...The documentation must differentiate skilled gait training rendered from assisted walking, when the patient is walking repetitiously and merely improving distance or endurance (assisted or non-assisted)."3
Link Impairments to Function
Coffman uses the concepts of linking impairments and functional limitations to write documentation that meets Medicare guidelines.2 Impairments are the consequence of disease, injury or pathological processes. They include abnormal strength and range of motion. Functional limitations occur when impairments restrict the patient's mobility, including walking and transfers.
An example of good documentation: "Patient ambulates 25 feet with wheeled walker and minimal assist with ankle in plantarflexion at initial contact and maintains knee flexion through stance. Gait deviations are due to decreased ankle dorsiflexor ROM and quad strength, which places the patient at risk of falls due to decreased stability with stance. Skilled treatment includes plantarflexor stretching and closed chain LE exercises emphasizing quad strength." This clearly describes the patient's gait deviations and related intervention.
In order to demonstrate to Medicare or other third-party payers that there is an expectation of progress, it is necessary to learn the details of the patient's prior level of function. Information from patients with cognitive deficits may need to be supplemented by reports from family and friends. The higher the patient's level of function, the more support there is for continued skilled services.
Many elderly patients in a nursing facility have multiple impairments affecting their gait and safety, such that a full written analysis and description of interventions could run to several pages. A patient at a Portland facility comes to mind, who has a history of CVA with mild L hemiparesis, decreased safety awareness, severe osteoarthritis of one knee with genu valgus, and moderate OA in both hips.
Under Medicare PPS, there is pressure to document quickly, since only direct time is billable. In cases like this, the process of documenting can serve as a way to think through what gait problems pose the biggest barrier to independence, and to decide which interventions take priority. Which interventions can the patient best learn and apply?
PTs and PTAs often find gait training to be one of the most rewarding services they provide. Documentation of skilled services can be a means to tap into our knowledge and abilities in this marvellously complex science of human locomotion.
1. Phillips, A. (2004). Rules and tools: Understanding the regulations that govern therapy services. Presentation, Fall Conference of the Oregon Physical Therapy Association, Portland.
2. Coffman, A. (2003). Documenting gait training for Medicare reimbursement. Topics in Geriatric Rehabilitation, 19(3), 220-226.
3. Centers for Medicare & Medicaid Services. (2002). Gait training (Article ID number A9836). Accessed via the World Wide Web, www.cms.hhs.gov
Emi Storey is clinical lead physical therapist for Consonus Rehab Services, based in Milwaukie, OR. An alumna of Stanford University, she has worked in long-term care for 13 years. Bob Thomas is a geriatric physical therapist and serves as director for Infinity Rehab, based in Wilsonville, OR. He lectures nationally for GREAT Seminars on rehab solutions for the elderly and is an adjunct professor at Pacific University.