CPT 97162 is used to describe the evaluation of a patient by a physical or occupational therapist in a clinical setting. This specific code refers to a level 2 evaluation, which is a moderate complexity assessment that involves a comprehensive patient history, examination of body systems, and clinical decision making. Therapists use this code to document and bill for their services related to the evaluation process.
Examples of when a physical or occupational therapist might use CPT 97162:
- Post-Stroke Rehabilitation: A patient who recently experienced a stroke and is referred to a physical therapist for an evaluation. The therapist would conduct a level 2 evaluation to assess the patient’s motor and sensory impairments, balance and coordination, and overall functional abilities. Based on the evaluation, the therapist would develop an individualized treatment plan to address the identified deficits and facilitate the patient’s recovery.
- Chronic Pain Management: A patient with persistent low back pain visits an occupational therapist for an evaluation. The therapist performs a moderate complexity assessment, including a comprehensive history taking, an evaluation of the patient’s posture, range of motion, muscle strength, and functional abilities. The therapist would then use this information to develop a targeted intervention plan, such as pain-relieving modalities, therapeutic exercises, and ergonomic education to help manage the patient’s pain and improve their daily activities.
- Orthopedic Injury: A patient who has undergone surgery for a rotator cuff repair is referred to a physical therapist for post-operative rehabilitation. The therapist would conduct a level 2 evaluation to assess the patient’s surgical site, range of motion, strength, and functional abilities. The information gathered during the evaluation would be used to create a tailored rehabilitation program that focuses on regaining shoulder mobility, strength, and function, as well as preventing future injuries.