CPT® Code 97161

The CPT® Code 97161 refers to a physical therapy evaluation characterized by low complexity. This evaluation is essential for establishing a baseline understanding of a patient's physical condition and determining an appropriate plan of care. During this evaluation, the physical therapist conducts a thorough history-taking process, which includes gathering information about the patient's current complaint, the onset of symptoms, any comorbidities that may influence treatment, previous treatments received, and medications currently prescribed. The therapist also performs a physical examination of the relevant body systems, utilizing standardized tests and measures to assess 1-2 elements related to body structures and functions, activity limitations, and participation restrictions. The clinical presentation of the patient is expected to exhibit stable and uncomplicated characteristics, allowing for straightforward clinical decision-making. This decision-making process is classified as low complexity and is based on standardized patient assessment instruments and measurable assessments of functional outcomes. Typically, the evaluation involves approximately 20 minutes of face-to-face interaction with the patient and/or their family, ensuring that all relevant information is collected to inform the subsequent treatment plan.