CPT 97161 is a procedural code used in the physical and occupational therapy fields. It refers to an initial evaluation of a patient with low complexity, typically involving a limited number of body systems or functional limitations. The evaluation process includes a thorough assessment of the patient’s medical history, physical examination, and clinical decision-making to determine the appropriate treatment plan.
Example 1: A patient presents with a recent ankle sprain and mild swelling, with no history of prior injuries or comorbidities. The therapist conducts an initial evaluation, assessing the patient’s range of motion, strength, and balance to create a treatment plan focused on reducing pain, improving mobility, and preventing further injury.
Example 2: An elderly patient with a history of occasional knee pain visits the therapist due to increased discomfort while walking. The therapist performs a low complexity evaluation, focusing on the patient’s gait, knee stability, and muscle strength. Based on the findings, the therapist develops a plan incorporating exercises to increase muscle strength and support the knee joint, along with balance training to minimize the risk of falls.
Example 3: A patient with mild carpal tunnel syndrome seeks occupational therapy to address symptoms and prevent worsening of the condition. The therapist conducts a low complexity evaluation, assessing the patient’s hand and wrist function, pain levels, and activities of daily living. The treatment plan includes therapeutic exercises, ergonomic adjustments to the patient’s work environment, and strategies to manage pain and inflammation.