How To Use CPT Code 97162

CPT 97162 refers to a moderate 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 97162?

CPT 97162 is a code used to describe a moderate complexity physical therapy evaluation. This evaluation is performed by a physical therapist and involves a comprehensive assessment of the patient’s condition, including their history, current status, and any factors that may impact their plan of care. The evaluation also includes standardized tests and measures to assess various aspects of the patient’s physical functioning.

2. 97162 CPT code description

The official description of CPT code 97162 is: “Physical therapy evaluation: moderate complexity, requiring these components: A history of 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.”

3. Procedure

  1. The physical therapist (PT) begins by taking a brief medical history of the patient, focusing on the present problem and any personal factors or comorbidities that may impact the plan of care.
  2. The PT assesses the patient’s current status for any evolving or changing characteristics that may affect the treatment plan.
  3. Using standardized tests and measures, the PT examines the patient’s body systems, addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
  4. The PT employs clinical decision-making of moderate complexity, using standardized patient assessment instruments and/or measurable assessments of functional outcomes.
  5. Typically, the PT spends 30 minutes of face-to-face time with the patient and/or family during the evaluation.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 97162 services are those who require a moderate complexity physical therapy evaluation. This may include patients with a history of present problems, one or two personal factors or comorbidities that impact the plan of care, and an evolving clinical presentation with changing characteristics. The evaluation must involve the examination of body systems using standardized tests and measures, addressing at least three elements from body structures and functions, activity limitations, and/or participation restrictions.

5. When to use CPT code 97162

It is appropriate to bill the 97162 CPT code when a physical therapist performs a moderate complexity physical therapy evaluation. This evaluation should include a history of the present problem, examination of body systems using standardized tests and measures, and clinical decision-making of moderate complexity. The evaluation should also involve at least 30 minutes of face-to-face time with the patient and/or family.

6. Documentation requirements

To support a claim for CPT 97162, the following information should be documented:

  • A brief medical history of the patient, focusing on the present problem and any personal factors or comorbidities that may impact the plan of care.
  • An assessment of the patient’s current status for any evolving or changing characteristics that may affect the treatment plan.
  • A detailed description of the standardized tests and measures used during the evaluation, as well as the results of these tests.
  • A summary of the clinical decision-making process, including the use of standardized patient assessment instruments and/or measurable assessments of functional outcomes.
  • The total face-to-face time spent with the patient and/or family during the evaluation.

7. Billing guidelines

When billing for CPT code 97162, it is essential to ensure that the evaluation meets the criteria for moderate complexity and that the appropriate documentation is provided to support the claim. Additionally, be aware of any specific payer guidelines or requirements related to billing for physical therapy services. It is also important to note that for physical therapy evaluations of low and high complexity, CPT codes 97161 and 97163 should be used, respectively. For the re-evaluation of an established plan of care, CPT code 97164 should be used.

8. Historical information

CPT 97162 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 97162

Five similar codes to CPT 97162 and how they differentiate are:

  1. CPT 97161: This code is used for a low complexity physical therapy evaluation, which involves fewer components and less clinical decision-making than a moderate complexity evaluation.
  2. CPT 97163: This code is used for a high complexity physical therapy evaluation, which involves more components and greater clinical decision-making than a moderate complexity evaluation.
  3. CPT 97164: This code is used for the re-evaluation of an established physical therapy plan of care, rather than an initial evaluation.
  4. CPT 97165: This code is used for an occupational therapy evaluation of low complexity, which focuses on occupational therapy-specific components and assessments.
  5. CPT 97166: This code is used for an occupational therapy evaluation of moderate complexity, similar to CPT 97162 but specific to occupational therapy services.

10. Examples

Here are 10 detailed examples of CPT code 97162 procedures:

  1. A patient with a recent stroke requires a moderate complexity physical therapy evaluation to assess their current functional status and develop a plan of care for rehabilitation.
  2. A patient with a history of chronic low back pain and obesity requires a moderate complexity physical therapy evaluation to determine the most appropriate treatment plan to address their pain and functional limitations.
  3. A patient with a recent total knee replacement requires a moderate complexity physical therapy evaluation to assess their post-operative status and develop a rehabilitation plan.
  4. A patient with multiple sclerosis experiences a decline in their mobility and requires a moderate complexity physical therapy evaluation to determine the most appropriate interventions to maintain their functional abilities.
  5. A patient with a traumatic brain injury requires a moderate complexity physical therapy evaluation to assess their current functional status and develop a plan of care for rehabilitation.
  6. A patient with a history of chronic neck pain and anxiety requires a moderate complexity physical therapy evaluation to determine the most appropriate treatment plan to address their pain and functional limitations.
  7. A patient with a recent hip fracture requires a moderate complexity physical therapy evaluation to assess their post-operative status and develop a rehabilitation plan.
  8. A patient with Parkinson’s disease experiences a decline in their mobility and requires a moderate complexity physical therapy evaluation to determine the most appropriate interventions to maintain their functional abilities.
  9. A patient with a spinal cord injury requires a moderate complexity physical therapy evaluation to assess their current functional status and develop a plan of care for rehabilitation.
  10. A patient with a history of chronic shoulder pain and depression requires a moderate complexity physical therapy evaluation to determine the most appropriate treatment plan to address their pain and functional limitations.

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