97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in

Name of the Procedure:

Physical Therapy Evaluation: Moderate Complexity

Summary

A physical therapy evaluation of moderate complexity involves assessing the patient's current medical problem with a focus on 1-2 personal factors and/or comorbidities that impact the treatment plan. This includes a detailed examination of various body systems through standardized tests and measures.

Purpose

The primary purpose of this evaluation is to diagnose issues related to movement and function that may be impacting the patient. The goals include creating a tailored treatment plan to improve mobility, reduce pain, and enhance overall functional ability.

Indications

• Chronic pain in muscles or joints
• Post-surgical rehabilitation
• Reduced mobility due to injury or disease
• Neurological conditions like stroke or Parkinson's disease
• Personal factors such as age or occupation that impact treatment

Preparation

• No specific fasting or dietary changes required
• Wear comfortable clothing that allows easy movement
• Bring a list of current medications and medical history

Procedure Description

1. Initial Interview:
   • The therapist gathers detailed information about the patient's current problem, medical history, and any personal factors or comorbidities.
2. Physical Examination:
   • Assessment of body systems including musculoskeletal, neuromuscular, cardiovascular, and respiratory using standardized tests.
3. Functional Tests:
   • Evaluation of gait, balance, strength, range of motion, and endurance.
4. Documentation and Planning:
   • The therapist documents findings and formulates a personalized care plan.

Duration

Approximately 60 to 90 minutes.

Setting

Typically performed in an outpatient clinic or a physical therapy center.

Personnel

• Licensed Physical Therapist (PT)

Risks and Complications

• Minimal risks associated with the evaluation
• Possible discomfort during certain physical tests
• Rare risks include muscle soreness or fatigue post-assessment

Benefits

• Accurate diagnosis of movement dysfunction
• Personalized treatment plan to address specific issues
• Early intervention leading to faster recovery and improved function

Recovery

• No recovery time required post-evaluation
• Patients may feel slight muscle soreness which typically resolves in a day
• Follow-up appointments may be scheduled to implement the treatment plan

Alternatives

• Self-assessment using online tools (less accurate)
• General medical examination (may not focus on movement and function)
• Directly starting general physical therapy without a detailed evaluation (less personalized approach)

Patient Experience

• The evaluation is generally pain-free but may involve some discomfort during specific tests.
• Patients are encouraged to give honest feedback about their pain or discomfort to ensure accurate assessment.
• Any discomfort experienced is usually mild and temporary, with pain management strategies provided if necessary.