Current Procedural Terminology (CPT) codes are standardized numerical identifiers used by healthcare providers to describe medical services and procedures. For physical therapy, a specific family of codes classifies the initial evaluation a patient receives. CPT Code 97162 is designated for a physical therapy evaluation deemed to be of moderate complexity. This classification allows the licensed physical therapist to communicate the depth of the initial assessment to third-party payers, establishing the foundation for the patient’s rehabilitation journey.
Understanding CPT Code 97162
The specific description for CPT Code 97162 is “Physical therapy evaluation, moderate complexity.” This code is used exclusively by a licensed physical therapist during the patient’s first encounter. This comprehensive assessment identifies the patient’s primary functional limitations and determines the most appropriate plan of care. It reflects an assessment that is more involved than a straightforward case but does not reach the highest level of intricacy.
The use of this code signifies that the patient’s condition requires a detailed assessment of multiple body systems and that the clinical presentation is not entirely predictable. While face-to-face time is typically estimated around 30 minutes, the determination is based on the complexity of the clinical reasoning, not the time spent. Applying this code requires the physical therapist to meet specific thresholds across three distinct components: the patient’s history, the physical examination, and the clinical decision-making process.
Specific Criteria for Moderate Complexity
The designation of moderate complexity for CPT 97162 is met when the patient’s presentation satisfies defined criteria across the history, examination, and decision-making components. Regarding the patient’s medical history, the code requires identifying one or two personal factors or pre-existing conditions (comorbidities) relevant to the current plan of care. These factors, such as controlled diabetes, mild obesity, or a prior surgery, influence the patient’s recovery or the safety of certain interventions. These existing health issues introduce layers of consideration that increase the complexity beyond a simple, isolated injury.
The physical examination component must involve assessing at least three distinct elements from body systems or areas. This includes evaluating the musculoskeletal system (strength, range of motion), the neuromuscular system (balance, coordination), and functional status (mobility, gait). The therapist must employ standardized tests and measures to collect objective data on these elements. This multi-system approach is necessary because the patient’s primary complaint often has secondary effects or underlying causes that require a broader investigation.
The final component is clinical decision-making, which must be of moderate complexity. This requires the therapist to synthesize data from the history and multi-system examination to develop the initial diagnosis and prognosis. The patient’s clinical presentation must be categorized as “evolving,” meaning the symptoms or functional status are changing, which necessitates a more dynamic analysis to establish the plan of care. For example, a patient recovering from a recent stroke or a severe flare-up of a chronic condition would typically meet the criteria.
Differentiating Levels of Physical Therapy Evaluation
CPT 97162 sits in the middle of a tiered system that includes CPT 97161 (low complexity) and CPT 97163 (high complexity). The low complexity code, 97161, is appropriate for patients whose history reveals no personal factors or comorbidities that impact the treatment plan. The examination for a low complexity case is more focused, requiring the assessment of only one or two elements.
In contrast, the high complexity code (97163) is reserved for patients with significantly more intricate clinical pictures. Billing 97163 requires documenting three or more personal factors or comorbidities that substantially affect the plan of care. The examination must be extensive, addressing at least four elements from various body systems, signifying a much broader physical assessment.
The clinical decision-making for a high complexity evaluation is categorized as unstable or unpredictable, demanding the most comprehensive analysis to create a safe and effective plan. Code 97162 is appropriate when the patient’s situation requires more than a simple, focused assessment but avoids the severe, multi-faceted history and unstable presentation characteristic of the highest complexity level. The selection of the correct code depends entirely on the therapist’s detailed clinical findings across all three required criteria.
Key Documentation Requirements
Justifying the use of CPT Code 97162 depends entirely on robust documentation supporting the moderate complexity designation. The physical therapist must clearly record the specific one or two personal factors or comorbidities identified during the history review. The notes must explicitly detail which three or more elements or body systems were examined, along with the objective results from standardized tests and measures used. This documented evidence demonstrates that the complexity thresholds for the code were met.
The evaluation documentation must also include a formalized written plan of care detailing the proposed therapeutic interventions. This plan must incorporate specific, measurable, achievable, relevant, and time-bound goals that directly correlate with the functional limitations identified. The therapist is required to certify that the recorded history, examination, and clinical decision-making substantiate the selection of the moderate complexity code, providing necessary administrative proof of medical necessity.