CPT codes standardize the description of medical services for billing and tracking purposes, ensuring accurate communication between healthcare providers and insurance companies. CPT Code 97162 is designated by the American Medical Association (AMA) for a physical or occupational therapy evaluation of moderate complexity. This code signifies that the patient’s initial assessment required a level of clinical skill and decision-making that falls between the lowest and highest complexity tiers.
Defining the Physical and Occupational Therapy Evaluation
The service described by CPT 97162 is the initial comprehensive assessment performed by a licensed Physical Therapist (PT) or Occupational Therapist (OT). This evaluation is the foundation of a patient’s care, where the therapist gathers data to determine functional status and establish measurable goals. The purpose of this process is to formulate an individualized plan of care that addresses the patient’s specific impairments and activity limitations.
This evaluation is generally performed early in a patient’s course of care to determine the need for therapeutic intervention. While the code is not strictly time-based, a moderate complexity evaluation typically involves approximately 30 minutes of face-to-face interaction with the patient or family. The use of this code confirms the patient presents with conditions requiring a moderate depth of analysis to initiate safe and effective treatment.
Clinical Criteria for Moderate Complexity
To correctly apply CPT 97162, the evaluation must satisfy specific requirements across three distinct components: patient history, examination, and clinical decision-making. All three factors must meet the “moderate complexity” threshold. If any component falls short, the therapist must select a lower complexity code, ensuring the billing accurately reflects the clinical work performed.
The first component, patient history, is considered moderate when the patient presents with one or two personal factors or pre-existing conditions (comorbidities) that affect the plan of care. Examples include stable, controlled conditions like mild obesity, early-stage diabetes, or previous injuries in a different anatomical area. The therapist must analyze how these one or two factors influence the patient’s current condition and potential for recovery.
The second component requires an examination addressing three or more elements from standardized categories of body structures and functions, activity limitations, or participation restrictions. This often involves assessing three or more body systems, such as the musculoskeletal, neuromuscular, and cardiorespiratory systems. The therapist employs standardized tests and measures to quantify elements like strength, range of motion, balance, and gait mechanics.
The third component is clinical presentation and decision-making, which must be rated as moderate complexity. This level is appropriate when the patient’s clinical presentation is described as evolving with changing characteristics, meaning symptoms or functional status are not entirely stable or predictable. The therapist’s decision-making involves interpreting this broader set of data and synthesizing multiple findings to develop a complex, multi-faceted treatment plan.
Understanding the Differences in Evaluation Levels
CPT 97162 is situated within a tiered system of three evaluation codes, allowing therapists to accurately select the code that matches the patient’s clinical needs. The low complexity code, 97161, is appropriate for patients with a stable, uncomplicated clinical presentation and no personal factors or comorbidities affecting the treatment plan. This typically involves a less detailed history review and an examination addressing only one or two elements of function or body structure.
The highest level, CPT 97163, is reserved for evaluations of high complexity. The patient presents with three or more personal factors or comorbidities that significantly impact the plan of care. This level is characterized by an unstable or unpredictable clinical presentation, requiring extensive data analysis and complex decision-making. The high complexity code requires a more exhaustive examination, addressing four or more elements of function or body structure, often involving a patient with severe or multi-system impairments.
The distinction between the codes is based on the patient’s condition and the resultant level of necessary clinical decision-making, not the therapist’s skill. For instance, a simple ankle sprain in a healthy individual would likely qualify for 97161. Conversely, a post-surgical knee patient with a history of severe cardiac disease and obesity would necessitate the highest code, 97163. CPT 97162 acts as the middle ground, applying to patients whose condition requires more than a basic assessment but lacks the severe instability or high number of comorbidities seen in the most complex cases.
Implementation and Record Keeping Standards
The accurate use of CPT 97162 requires meticulous documentation to support the chosen level of complexity for payer review. The initial evaluation note must explicitly detail the one to two comorbidities considered and clearly outline the three or more elements of the examination performed. This comprehensive charting serves as the justification for the moderate complexity level, demonstrating medical necessity and supporting the billing claim.
CPT 97162 is typically billed only once per episode of care for the initial comprehensive evaluation. If a patient experiences a significant change in medical status or develops a new complication unrelated to the initial injury, a re-evaluation code (CPT 97164) may be warranted instead. Adherence to these documentation standards is paramount, as insurance payers, including federal programs like Medicare, require evidence that all three criteria for moderate complexity were met before authorizing reimbursement.