CPT® Code 97171

1. Indications

The athletic training evaluation coded as CPT® 97171 is indicated for patients who present with complex athletic injuries or conditions that require a detailed assessment. The following are the specific indications for performing this high complexity evaluation:

• Multiple Comorbidities The patient has three or more comorbidities that affect their physical activity, necessitating a comprehensive evaluation to understand the interplay between these conditions and their athletic performance.
• Complex Clinical Presentation The patient exhibits unstable and unpredictable characteristics in their clinical presentation, which requires a thorough assessment to determine the appropriate course of action.
• Need for Comprehensive Examination The evaluation is warranted when a comprehensive examination of body systems is necessary, addressing four or more elements related to body structures, physical activity, and/or participation deficiencies.
• High Complexity Clinical Decision Making The situation demands high complexity clinical decision-making, utilizing standardized patient assessment instruments and measurable assessments of functional outcomes to guide treatment.

2. Procedure

The procedure for conducting an athletic training evaluation of high complexity involves several detailed steps to ensure a thorough assessment of the patient's condition. Each step is critical to developing an effective rehabilitation and prevention program.

• Step 1: Medical History and Physical Activity Profile The evaluation begins with a comprehensive collection of the patient's medical history, including current and past injuries, as well as a detailed physical activity profile. This step is crucial for identifying any comorbidities that may impact the patient's athletic performance and overall physical activity.
• Step 2: Comprehensive Examination Following the medical history, a thorough examination of the affected body area(s) or system(s) is performed. This examination utilizes standardized tests and measures to assess a variety of physical parameters, including range of motion, strength, flexibility, agility, speed, endurance, and power. Additionally, tests related to circulation and sensation are conducted to provide a complete picture of the patient's physical capabilities.
• Step 3: Clinical Decision Making Based on the findings from the medical history and physical examination, the athletic trainer engages in high complexity clinical decision-making. This involves using standardized patient assessment instruments and measurable assessments of functional outcomes to determine the most appropriate rehabilitation and training program tailored to the patient's needs.
• Step 4: Development of Rehabilitation and Prevention Program The final step involves the formulation of a comprehensive rehabilitation, training, and prevention program. This program is designed to address the specific needs identified during the evaluation and aims to enhance the patient's recovery while preventing future injuries.

3. Post-Procedure

After the athletic training evaluation, the patient may require ongoing monitoring and follow-up appointments to assess their progress. During these follow-ups, the athletic trainer will evaluate the patient's response to the treatment plan and make necessary adjustments based on the patient's current functional status and any documented changes. This iterative process ensures that the rehabilitation and prevention strategies remain effective and aligned with the patient's evolving needs. Additionally, education on injury prevention and self-management strategies may be provided to empower the patient in their recovery journey.