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CPT Code 97162 | Moderate Complexity Physical Therapy Evaluation

CPT code 97162 is for a moderate complexity physical therapy evaluation that includes a medical history review, physical assessment with standardized tests, clinical decision-making, and discussion of care plans in a 30-minute face-to-face session with the patient and/or family.

What Is CPT Code 97162?

CPT 97162 refers to a physical therapy evaluation of moderate complexity that involves taking a brief medical history, assessing the patient’s physical characteristics using standardized tests and measurements, and using clinical decision-making to determine a care plan.

This evaluation typically lasts 30 minutes face-to-face with the patient and/or family and may include a discussion of the diagnosis and potentially physical therapy interventions.

The physical therapist may assess the patient’s muscle strength, flexibility, balance, coordination, gross neuromuscular status, mobility, and any prosthetic devices present.”


The CPT book describes CPT code 97162 as: “Physical therapy evaluation: moderate complexity, requiring these components: A history of the present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.”


The physical therapist (PT) performs a general overall evaluation of the patient. The PT takes a brief medical history. The PT assesses the patient’s history and current status for any evolving or changing characteristics that interfere with the care plan.

She analyzes the patient’s muscle strength, flexibility, balance, coordination, gross neuromuscular status, and mobility. The PT also reviews the condition of any prosthetic device, if present.

The patient may be asked to perform a variety of movements throughout this evaluation. Throughout the assessment, the PT uses standardized tests and measurements, i.e., criteria established and agreed upon by a group of experts.

Using clinical decision–making of moderate complexity, the PT spends approximately 30 minutes of face–to–face time with the patient and/or family.

Finally, the PT summarizes her clinical findings in the Assessment and Planning section of the SOAP note section of the evaluation sheet.

The PT also may discuss the diagnosis and possibly physical therapy intervention and its benefits with the patient and family.

How To Use CPT 97162

CPT 97162 may only be used for physical therapy evaluation of moderate complexity.

Report CPT 97161 and CPT 97163 for low and high-complexity physical therapy evaluation.

Report CPT code 97164 for the re-evaluation of the established plan of care.


CPT Professional 2022

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