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Code deleted. See 97161-97172.

Official Description

Physical therapy re-evaluation

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A physical therapy re-evaluation, identified by CPT® Code 97002, is a critical component of the physical therapy process. This procedure is conducted to assess a patient's progress and response to previously implemented treatment strategies. During a re-evaluation, the physical therapist gathers an interim history, which includes updates on the patient's current condition, any changes in symptoms, and the effectiveness of the treatment received since the last evaluation. The therapist will inquire about the patient's experiences with their symptoms, including any activities or movements that may exacerbate or alleviate their condition. This process is essential for determining the next steps in the patient's care plan. The physical therapist will also evaluate the patient's response to treatment, which may involve reassessing joint flexibility, muscle strength, general mobility, posture, and core strength. Based on this comprehensive assessment, the therapist will revise the plan of care to ensure it aligns with the patient's current needs and goals, thereby optimizing the effectiveness of the physical therapy interventions.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The physical therapy re-evaluation (CPT® Code 97002) is indicated for patients who have undergone a previous physical therapy evaluation and have received treatment for their condition. The re-evaluation is performed to assess the effectiveness of the treatment and to make necessary adjustments to the plan of care. Specific indications for this procedure may include:

  • Change in Symptoms The patient reports changes in their symptoms, such as increased pain, decreased mobility, or new functional limitations.
  • Response to Treatment The patient’s response to the current treatment plan needs to be evaluated to determine its effectiveness and appropriateness.
  • Progress Monitoring Regular monitoring of the patient's progress is necessary to ensure that the treatment goals are being met and to facilitate timely modifications to the care plan.

2. Procedure

The procedure for a physical therapy re-evaluation involves several key steps that ensure a comprehensive assessment of the patient's current status. These steps include:

  • Interim History Collection The physical therapist begins by taking an interim history from the patient. This includes asking about any changes in symptoms since the last evaluation, the effectiveness of the treatment received, and any new medications or treatments the patient may have started.
  • Assessment of Symptoms The therapist evaluates the patient's response to treatment by discussing specific activities or movements that may exacerbate or relieve symptoms. This helps in understanding the patient's current functional status and challenges.
  • Physical Assessment A physical assessment is conducted, which may include tests for joint flexibility, muscle strength, and evaluations of general mobility, posture, and core strength. The therapist may also assess muscle tone and identify any restrictions in movement that could be related to myofascial disorders.
  • Plan of Care Revision Based on the findings from the interim history and physical assessment, the physical therapist will revise the plan of care. This may involve adjusting treatment modalities, frequency of therapy sessions, and recommending home exercises or environmental modifications to support the patient's recovery.

3. Post-Procedure

After the physical therapy re-evaluation, the patient may be provided with updated instructions regarding their treatment plan. This may include recommendations for continued physical therapy sessions, specific exercises to perform at home, and any lifestyle modifications that could aid in their recovery. The therapist will also schedule follow-up appointments to monitor the patient's progress and make further adjustments to the plan of care as needed. It is essential for the patient to adhere to the revised plan to achieve optimal outcomes and improve their overall functional abilities.

Short Descr PT RE-EVALUATION
Medium Descr PHYSICAL THERAPY RE-EVALUATION
Long Descr Physical therapy re-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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