CPT® Code 97169

Official Description

Athletic training evaluation, low complexity, requiring these components:

A history and physical activity profile with no comorbidities that affect physical activity;
An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and
Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

Typically, 15 minutes are spent face-to-face with the patient and/or family.

Common Language Description

An athletic training evaluation, specifically coded as CPT® 97169, refers to a low complexity assessment performed by an athletic trainer. This evaluation is essential for understanding the current athletic injuries of a patient and for implementing strategies to prevent future injuries. The evaluation process begins with gathering a comprehensive medical history, which includes details about current and past injuries, any comorbidities that may influence physical activity, and a profile of the patient's physical activity levels. Following the history, a thorough physical examination is conducted on the affected body area or related systems. This examination assesses various physical parameters such as range of motion, strength, flexibility, agility, speed, endurance, and power. Additionally, tests related to circulation and sensation are performed to ensure a complete understanding of the patient's condition. The athletic trainer utilizes the information gathered during the evaluation to formulate a tailored rehabilitation, training, and prevention program. This program is based on clinical decision-making that incorporates standardized patient assessment instruments and measurable outcomes of functional performance. The typical duration of this face-to-face interaction with the patient and/or their family is approximately 15 minutes. This structured approach not only addresses immediate concerns but also sets the foundation for ongoing care and monitoring of the patient's athletic health.

1. Indications

The athletic training evaluation coded as CPT® 97169 is indicated for patients who require assessment of athletic injuries and the development of prevention strategies. The specific indications include:

Current Athletic Injuries Evaluation of injuries sustained during athletic activities to determine the extent and nature of the injury.
Prevention of Recurrent Injuries Assessment aimed at identifying risk factors and implementing strategies to prevent future injuries.
Medical History Review Gathering information on past injuries and comorbidities that may affect physical activity.

2. Procedure

The procedure for conducting an athletic training evaluation of low complexity involves several key steps, which are detailed as follows:

Step 1: History and Physical Activity Profile The athletic trainer begins by collecting a comprehensive history from the patient, which includes details about current and past injuries, as well as any comorbidities that may impact the patient's ability to engage in physical activity. This step is crucial for understanding the patient's overall health and activity levels.
Step 2: Examination of Affected Body Area Following the history, the trainer conducts a physical examination of the affected body area and any related systems. This examination focuses on assessing 1-2 elements from the categories of body structures, physical activity, and/or participation deficiencies. The trainer evaluates various physical parameters, including range of motion, strength, flexibility, agility, speed, endurance, and power, to gain a comprehensive understanding of the patient's condition.
Step 3: Clinical Decision Making After the examination, the athletic trainer engages in clinical decision-making of low complexity. This involves using standardized patient assessment instruments and/or measurable assessments of functional outcomes to guide the development of a rehabilitation, training, and prevention program tailored to the patient's needs.

3. Post-Procedure

Post-procedure care following an athletic training evaluation typically involves monitoring the patient's response to the implemented rehabilitation and training program. The athletic trainer may schedule follow-up appointments to assess progress, make necessary adjustments to the treatment plan, and ensure that the patient is on track to achieve their athletic goals. The trainer will also provide guidance on exercises and activities that the patient can safely engage in during their recovery. Continuous evaluation and re-assessment are essential to adapt the program based on the patient's evolving functional status and any changes in their condition.

Short Descr	ATHLETIC TRN EVAL LOW CMPLX
Medium Descr	ATHLETIC TRAINING EVAL LOW COMPLEX 15 MINS
Long Descr	Athletic training evaluation, low complexity, requiring these components: A history and physical activity profile with no comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 15 minutes are spent face-to-face with the patient and/or family.
Status Code	Non-Covered Service
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Non-Covered Service, not paid under OPPS
Type of Service (TOS)	1 - Medical Care
Berenson-Eggers TOS (BETOS)	M5D - Specialist - other
MUE	0

Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.

Services delivered under an outpatient physical therapy plan of care