CPT® Code 97001

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1. Indications

The physical therapy evaluation (CPT® Code 97001) is indicated for patients experiencing a variety of musculoskeletal or neuromuscular conditions. The following are specific indications for performing this evaluation:

• Musculoskeletal Pain Patients presenting with pain in muscles, joints, or connective tissues that may require physical therapy intervention.
• Post-Surgical Rehabilitation Individuals recovering from surgical procedures who need assessment to guide their rehabilitation process.
• Injury Assessment Patients with recent injuries, such as sprains, strains, or fractures, requiring evaluation to determine the extent of damage and appropriate treatment.
• Chronic Conditions Individuals with chronic conditions such as arthritis or fibromyalgia that may benefit from physical therapy to manage symptoms and improve function.
• Neurological Disorders Patients with neurological conditions, such as stroke or multiple sclerosis, needing evaluation to develop a tailored rehabilitation plan.

2. Procedure

The procedure for a physical therapy evaluation involves several key steps that ensure a thorough assessment of the patient's condition. Each step is critical for developing an effective treatment plan.

• Step 1: Patient History The physical therapist begins by taking a comprehensive history of the patient's current complaint. This includes gathering information about the onset of symptoms, any changes since the onset, previous treatments received, and medications prescribed for the condition, as well as any other medications the patient is currently taking.
• Step 2: Symptom Assessment The therapist engages the patient in identifying specific activities or movements that exacerbate their symptoms, as well as those that provide relief. This dialogue helps to pinpoint the factors contributing to the patient's condition.
• Step 3: Physical Examination A thorough physical examination is conducted, which may include provocative maneuvers to identify movements that trigger symptoms, tests for joint flexibility and muscle strength, and assessments of general mobility, posture, and core strength. The therapist also evaluates muscle tone and tests for restrictions of movement caused by myofascial disorders.
• Step 4: Condition Explanation After completing the history and physical examination, the physical therapist provides a detailed explanation of the patient's condition. This includes discussing the findings from the evaluation and how they relate to the patient's symptoms.
• Step 5: Treatment Options The therapist identifies potential physical therapy treatment options tailored to the patient's needs and explains how often and how long these modalities should be applied.
• Step 6: Plan of Care Development Finally, the physical therapist develops a personalized plan of care, which may include both in-clinic physical therapy sessions and recommendations for home exercises or environmental modifications to help alleviate symptoms.

3. Post-Procedure

Post-procedure care following a physical therapy evaluation involves monitoring the patient's response to the initial treatment plan. The physical therapist may schedule follow-up appointments to assess progress and make necessary adjustments to the plan of care. Patients are encouraged to communicate any changes in their symptoms or concerns during these follow-ups. Additionally, the therapist may provide guidance on home exercises and lifestyle modifications to support recovery and enhance the effectiveness of the therapy. Regular re-evaluations may be conducted to ensure that the treatment remains aligned with the patient's evolving needs and goals.