How To Use CPT Code 97161

CPT 97161 refers to a low complexity physical therapy evaluation, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 97161?

CPT 97161 is a code used to describe a low complexity physical therapy evaluation. This evaluation is typically performed by a physical therapist and involves a history, examination, clinical presentation, and clinical decision-making process. The purpose of this evaluation is to assess the patient’s physical condition and determine the appropriate plan of care for their specific needs.

2. 97161 CPT code description

The official description of CPT code 97161 is: “Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.”

3. Procedure

1. The physical therapist (PT) begins by taking a brief medical history of the patient, ensuring there are no personal factors or comorbidities that would impact the plan of care.
2. The PT conducts an examination of the patient’s body system(s) using standardized tests and measures, addressing 1-2 elements from body structures and functions, activity limitations, and/or participation restrictions.
3. The clinical presentation of the patient is assessed, ensuring it is stable and uncomplicated.
4. Using standardized patient assessment instruments and/or measurable assessments of functional outcomes, the PT engages in clinical decision-making of low complexity.
5. Approximately 20 minutes of face-to-face time is spent with the patient and/or family during the evaluation.

4. Qualifying circumstances

Patients eligible to receive CPT code 97161 services are those who require a low complexity physical therapy evaluation. This includes patients with stable and uncomplicated clinical presentations, and those without personal factors or comorbidities that would impact the plan of care. The evaluation should be focused on addressing 1-2 elements from body structures and functions, activity limitations, and/or participation restrictions.

5. When to use CPT code 97161

It is appropriate to bill the 97161 CPT code when a patient requires a low complexity physical therapy evaluation. This evaluation should be conducted by a physical therapist and involve a history, examination, clinical presentation, and clinical decision-making process. The evaluation should be focused on addressing 1-2 elements from body structures and functions, activity limitations, and/or participation restrictions, and typically involves 20 minutes of face-to-face time with the patient and/or family.

6. Documentation requirements

To support a claim for CPT 97161, the following information should be documented:

• A brief medical history, including the absence of personal factors and comorbidities that would impact the plan of care
• Examination findings, including standardized tests and measures used to assess 1-2 elements from body structures and functions, activity limitations, and/or participation restrictions
• A description of the patient’s clinical presentation, confirming it is stable and uncomplicated
• Clinical decision-making process, including the use of standardized patient assessment instruments and/or measurable assessments of functional outcomes
• Face-to-face time spent with the patient and/or family, typically 20 minutes

7. Billing guidelines

When billing for CPT code 97161, it is important to ensure that the patient meets the qualifying circumstances for a low complexity physical therapy evaluation. Additionally, proper documentation should be maintained to support the claim, including the medical history, examination findings, clinical presentation, clinical decision-making process, and face-to-face time spent with the patient and/or family. It is also essential to be aware of any specific payer guidelines or requirements related to billing for physical therapy services.

8. Historical information

CPT 97161 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to the code since its addition.

9. Similar codes to CPT 97161

Five similar codes to CPT 97161 include:

1. CPT 97162: This code is used for a moderate complexity physical therapy evaluation, which involves a more comprehensive history, examination, and clinical decision-making process.
2. CPT 97163: This code is used for a high complexity physical therapy evaluation, which involves an even more extensive history, examination, and clinical decision-making process.
3. CPT 97164: This code is used for a physical therapy re-evaluation, which is performed to assess the patient’s progress and update the plan of care as needed.
4. CPT 97165: This code is used for an occupational therapy evaluation, which focuses on the patient’s ability to perform activities of daily living and functional tasks.
5. CPT 97166: This code is used for a moderate complexity occupational therapy evaluation, which involves a more comprehensive history, examination, and clinical decision-making process.

10. Examples

Here are 10 detailed examples of CPT code 97161 procedures:

1. A patient with a recent ankle sprain requires a low complexity physical therapy evaluation to assess their range of motion, strength, and functional limitations.
2. A patient with mild low back pain requires a low complexity physical therapy evaluation to determine the appropriate treatment plan and exercises to address their pain and limitations.
3. A patient recovering from a minor knee surgery requires a low complexity physical therapy evaluation to assess their progress and determine the appropriate plan of care for their rehabilitation.
4. A patient with a stable and uncomplicated shoulder injury requires a low complexity physical therapy evaluation to assess their range of motion, strength, and functional limitations.
5. A patient with mild balance issues requires a low complexity physical therapy evaluation to determine the appropriate treatment plan and exercises to improve their balance and reduce their risk of falls.
6. A patient with a recent wrist fracture requires a low complexity physical therapy evaluation to assess their range of motion, strength, and functional limitations following immobilization.
7. A patient with a stable and uncomplicated hip injury requires a low complexity physical therapy evaluation to assess their range of motion, strength, and functional limitations.
8. A patient with mild neck pain requires a low complexity physical therapy evaluation to determine the appropriate treatment plan and exercises to address their pain and limitations.
9. A patient recovering from a minor elbow surgery requires a low complexity physical therapy evaluation to assess their progress and determine the appropriate plan of care for their rehabilitation.
10. A patient with a stable and uncomplicated foot injury requires a low complexity physical therapy evaluation to assess their range of motion, strength, and functional limitations.