What CPT codes are used for physical therapy evaluations?

Initial PT evaluations use 97161 (low complexity), 97162 (moderate complexity), or 97163 (high complexity). Code selection is based on history, examination, and clinical decision making. Most evaluations qualify for 97162 or 97163. Re-evaluations use 97164.

How do I document to support evaluation complexity level?

For 97163 (high complexity), document: personal factors and/or comorbidities that impact the plan, examination of body systems using standardized tests, and clinical presentation requiring significant modification of treatment approach. Include objective measurements like ROM, strength testing, and functional assessments.

What are the documentation requirements for PT treatment codes?

Treatment codes require documentation of skilled intervention, medical necessity, and patient response. 97110 (therapeutic exercise) needs exercise type, sets/reps, and therapeutic goal. 97140 (manual therapy) requires technique used, body region, and treatment rationale. Time must be documented for timed codes (minimum 8 minutes per unit).

How do I write measurable physical therapy goals?

Goals should be SMART: Specific, Measurable, Achievable, Relevant, Time-bound. Example: 'Patient will increase knee flexion ROM from 90° to 120° within 4 weeks to enable stair climbing.' Include baseline measurements, target values, functional outcomes, and timeframes.

What is required for PT plan of care documentation?

Plan of care must include: diagnosis, treatment goals (short and long-term), proposed interventions, frequency and duration of treatment, and anticipated discharge status. Medicare requires physician certification for outpatient PT services and progress reports at regular intervals.

Physical Therapy Evaluation Template - PT Initial Eval

Patient Information

Date: [Date]
Visit Type: Initial Evaluation
Referring Provider: [Name]
Diagnosis (Medical): [Diagnosis]

Subjective

Chief Complaint: [Primary area of pain or dysfunction] Mechanism of Injury: [Traumatic / Insidious / Post-operative] Date of Injury/Onset: [Date] Pain:

Current: [0-10] / Worst: [0-10] / Best: [0-10]
Description: [Sharp, dull, aching, burning]
Aggravating factors: [Movement, position, activity]
Alleviating factors: [Rest, ice, meds]

Functional Status:

Prior Level of Function (PLOF): Independent / Assist needed
Current Limitations: [Walking, sleeping, lifting, ADLs]

Medical History: [Relevant comorbidities, past surgeries]

Objective

Observation:

Posture: [Forward head, kyphosis, lordosis]
Gait: [Antalgic, step length, assistive device]
Swelling/Edema: [Location and grade]

Range of Motion (ROM):

[Joint]: Flexion [X]° / Extension [X]° (L/R)
[Joint]: Abduction [X]° / Rotation [X]° (L/R)

Strength (MMT):

[Muscle Group]: [0-5]/5 (L/R)
[Muscle Group]: [0-5]/5 (L/R)

Palpation:

Tenderness: [Anatomic location]
Muscle Tone: [Spasm, tight bands]

Special Tests:

[Test Name]: Positive / Negative
[Test Name]: Positive / Negative

Neurological:

Sensation: Intact / Impaired [dermatome]
Reflexes: [0-4+]

Assessment

Clinical Impression:

Patient presents with signs and symptoms consistent with [Diagnosis], resulting in deficits in [ROM, Strength, Endurance] limiting [Functional Activity]. Patient would benefit from skilled physical therapy to improve [Goals].

Prognosis: Excellent / Good / Fair / Poor

Plan of Care

Frequency: [X] times per week for [X] weeks Interventions:

Therapeutic Exercise (97110): [Strengthening, ROM]
Neuromuscular Re-ed (97112): [Balance, proprioception]
Manual Therapy (97140): [Mobilization, STM]
Modalities: [Ultrasound, e-stim]

Goals (Short Term - 2-4 weeks):

1. Reduce pain to [X]/10.
2. Increase [Joint] ROM to [X]°.
3. Improve functional score (e.g., LEFS/DASH) by [X] points.

Goals (Long Term - 6-8 weeks):

1. Return to [Specific Activity] without pain.
2. Full ROM and Strength within functional limits.
3. Independent with HEP.

Physical Therapy — Initial Evaluation Template

Template

Patient Information

Subjective

Objective

Assessment

Plan of Care

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