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Code deleted. See 97161-97172.

Official Description

Physical therapy evaluation

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A physical therapy evaluation, designated by CPT® Code 97001, is a comprehensive assessment conducted by a licensed physical therapist to determine a patient's physical therapy needs. This evaluation is crucial for establishing a baseline understanding of the patient's condition and formulating an effective treatment plan. During the initial evaluation, the physical therapist gathers a detailed history of the patient's current complaint, which includes the onset of symptoms, any changes that have occurred since the onset, previous treatments received, and any medications prescribed for the condition, as well as other medications the patient may be taking. The therapist also engages the patient in identifying specific activities or movements that exacerbate their symptoms, as well as those that provide relief. This interactive process is essential for tailoring the treatment to the individual needs of the patient. The evaluation may include various assessments such as provocative maneuvers—movements or positions that trigger symptoms—tests for joint flexibility and muscle strength, evaluations of general mobility, posture, and core strength, assessments of muscle tone, and tests for movement restrictions due to myofascial disorders. Following the history and physical examination, the physical therapist provides a detailed explanation of the patient's condition, discusses potential physical therapy treatment options, and outlines the frequency and duration of the recommended physical therapy modalities. The therapist then develops a personalized plan of care, which may encompass both in-clinic physical therapy sessions and home exercises or modifications to the patient's environment aimed at alleviating symptoms. In cases of re-evaluation, the therapist conducts an interim history, assesses the patient's response to the ongoing treatment, and adjusts the plan of care accordingly to ensure optimal outcomes.

© Copyright 2025 Coding Ahead. All rights reserved.

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.

Short Descr PT EVALUATION
Medium Descr PHYSICAL THERAPY EVALUATION
Long Descr Physical therapy evaluation
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 7 - Physical Therapy Service, for which Payment may not be Made
Multiple Procedures (51) 5 - Subject to 20%/25% reduction of the practice expense component...
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 9 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
Type of Service (TOS) 1 - Medical Care
Berenson-Eggers TOS (BETOS) M5D - Specialist - other
MUE Not applicable/unspecified.
CCS Clinical Classification 212 - Diagnostic physical therapy
GP Services delivered under an outpatient physical therapy plan of care
Date
Action
Notes
2016-12-31 Deleted Code deleted. See 97161-97172.
1998-01-01 Added First appearance in code book in 1998.
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