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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.
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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:
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.
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 |