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Official Description

Motor-cognitive, semi-immersive virtual reality-facilitated gait training, each 15 minutes (List separately in addition to code for primary procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Motor-cognitive, semi-immersive virtual reality-facilitated gait training is an innovative rehabilitation technique that integrates both motor and cognitive skills to enhance gait recovery. This procedure utilizes a sophisticated virtual reality simulator system, which includes a television, a depth camera, a computer, and a touchscreen interface. The semi-immersive nature of this system allows for a unique training environment where the camera is strategically positioned to track the patient's feet as they walk on a treadmill. As the patient engages in the training, they are able to see a real-time representation of their own feet in motion displayed on the television screen in front of them. This visual feedback is crucial as it helps the patient understand their gait dynamics and make necessary adjustments. During the gait-training session, patients navigate through a simulated environment that presents various obstacles, requiring them to engage in cognitive tasks simultaneously. These tasks may include determining which distractions to ignore, recognizing different types of objects that appear in their path, remembering the locations of these objects, and modulating their gait to effectively avoid potential hazards. This dual focus on motor function and cognitive processing is designed to improve overall gait performance and enhance the patient's ability to walk safely and efficiently in real-world settings.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The motor-cognitive, semi-immersive virtual reality-facilitated gait training is indicated for patients who require rehabilitation for gait-related issues. This may include individuals recovering from neurological conditions, orthopedic injuries, or other impairments that affect their ability to walk. The procedure is particularly beneficial for those who need to improve both their motor skills and cognitive functions simultaneously to enhance their overall mobility and safety while walking.

  • Neurological Conditions Patients with conditions such as stroke, traumatic brain injury, or multiple sclerosis may benefit from this training to regain their walking abilities.
  • Orthopedic Injuries Individuals recovering from surgeries or injuries affecting the lower extremities may use this procedure to improve their gait mechanics.
  • Balance and Coordination Issues Patients experiencing difficulties with balance or coordination can utilize this training to enhance their stability while walking.

2. Procedure

The procedure for motor-cognitive, semi-immersive virtual reality-facilitated gait training involves several key steps that ensure effective rehabilitation. Each session is structured to provide a comprehensive training experience.

  • Step 1: Setup of the Virtual Reality System The first step involves setting up the virtual reality simulator system, which includes positioning the depth camera to accurately track the patient's feet as they walk on the treadmill. The television screen is also set up to display the patient's foot movements in real-time, providing immediate visual feedback.
  • Step 2: Patient Preparation The patient is then prepared for the session, which may include explaining the procedure and ensuring they are comfortable with the equipment. The therapist may also assess the patient's baseline gait and cognitive abilities to tailor the session to their specific needs.
  • Step 3: Engagement in Gait Training During the training, the patient walks on the treadmill while interacting with the virtual environment displayed on the screen. They are required to navigate through obstacles and engage in cognitive tasks, such as identifying objects and making decisions about their movements.
  • Step 4: Feedback and Adjustment Throughout the session, the therapist provides feedback based on the patient's performance, helping them to adjust their gait and cognitive strategies as needed. This immediate feedback is crucial for reinforcing learning and improving gait mechanics.
  • Step 5: Session Conclusion At the end of the session, the therapist may conduct a debriefing with the patient to discuss their experience, review progress, and set goals for future sessions. This step is essential for ensuring continuity of care and motivation for the patient.

3. Post-Procedure

After completing the motor-cognitive, semi-immersive virtual reality-facilitated gait training session, patients may experience a range of outcomes. It is important for the therapist to monitor the patient's recovery and provide guidance on post-procedure care. Patients are typically encouraged to engage in light physical activity to reinforce the skills learned during the session. Additionally, follow-up sessions may be scheduled to continue the rehabilitation process, allowing for ongoing assessment and adjustment of the training program based on the patient's progress. Patients should also be advised to report any discomfort or concerns that arise following the session to ensure their safety and well-being during the rehabilitation process.

Short Descr MOTR COG VR GAIT TRAIN EA 15
Medium Descr MOTOR COG SEMI-IMMRSV VR FACIL GAIT TRAING EA 15
Long Descr Motor-cognitive, semi-immersive virtual reality-facilitated gait training, each 15 minutes (List separately in addition to code for primary procedure)
Status Code Carriers Price the Code
Global Days ZZZ - Code Related to Another Service
PC/TC Indicator (26, TC) 7 - Physical Therapy Service, for which Payment may not be Made
Multiple Procedures (51) 5 - Special payment adjustment rules on the RVU practice expense component of multiple therapy service applies...
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
Berenson-Eggers TOS (BETOS) none
MUE 2

This is an add-on code that must be used in conjunction with one of these primary codes.

97116 Telehealth Service (Medicare) Telemedicine Service (AMA) MPFS Status: Active Code APC A PUB 100 CPT Assistant Article Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
GP Services delivered under an outpatient physical therapy plan of care
Date
Action
Notes
2024-01-01 Added First appearance in code book.
2023-07-01 Added Code added.
Code
Description
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