CPT® Code 97162

The CPT® Code 97162 refers to a physical therapy evaluation characterized by moderate complexity. This evaluation is essential for establishing a comprehensive understanding of the patient's current physical condition and the factors influencing their treatment plan. During this evaluation, the physical therapist conducts a thorough history of the present problem, which includes gathering information about the onset of symptoms, any personal factors or comorbidities that may affect the patient's care, and previous treatments or medications related to the condition. The evaluation also involves a detailed examination of body systems, utilizing standardized tests and measures to assess at least three elements from the categories of body structures and functions, activity limitations, and participation restrictions. The clinical presentation of the patient is expected to evolve, indicating that the characteristics of their condition may change over time. This necessitates clinical decision-making of moderate complexity, which is informed by standardized patient assessment instruments and measurable assessments of functional outcomes. Typically, the physical therapist spends approximately 30 minutes in a face-to-face interaction with the patient and/or their family, ensuring that all relevant information is collected to formulate an effective plan of care. This structured approach not only aids in diagnosing the patient's condition but also in determining the most appropriate therapeutic interventions tailored to their specific needs.