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Evaluation Codes (CPT Codes 97001 and 97002 for physical therapy) and (CPT Codes 97003 and 97004 for occupational therapy)

The initial evaluation identifies the problem or difficulty the patient is having which helps determine the appropriate therapy necessary to treat the patient. An evaluation is a comprehensive service requiring professional skills to make clinical judgments about conditions for which services are indicated. If a new diagnosis/problem is encountered, then an additional evaluation may be appropriate to determine what course of treatment is necessary for the separate identifiable diagnosis/problem.

Re-evaluations are indicated periodically when the professional assessment indicates a significant improvement or decline in the patient’s condition or functional status. The re-evaluation focuses on the patient’s progress toward current goals. Professional judgment is used to determine continued care, modifying goals and/or treatment or terminating services.

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