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Re-evaluation of athletic training established plan of care requiring these components: An assessment of patient's current functional status when there is a documented change; and A revised plan of care using a standardized patient assessment instrument a

CPT4 code

Name of the Procedure:

Re-evaluation of Athletic Training Established Plan of Care (Revised Plan of Care Assessment)

Summary

This procedure involves assessing an athlete's current functional status when there has been a documented change in their condition. Subsequently, a revised plan of care is developed using a standardized assessment tool to ensure the athlete’s rehabilitation and training needs are effectively addressed.

Purpose

This re-evaluation addresses changes in the athlete's physical status and modifies the existing training and rehabilitation plan to optimize recovery and performance. The goals are to accurately assess the athlete's current capabilities, address any new or ongoing issues, and adjust the care plan to promote optimal recovery and performance.

Indications

  • Documented change in the athlete’s functional status.
  • New symptoms or worsening of existing symptoms.
  • After surgical procedures or significant injuries.
  • Changes in performance metrics.

Patient criteria include evidence of a change in condition that impacts the previously established training plan and necessitates a reassessment.

Preparation

  • No specific preparation required for the assessment itself.
  • Patient should provide a detailed update of their current condition and any changes since the last evaluation.
  • Review of recent medical records, imaging, or lab results may be necessary.

Procedure Description

  1. Assessment:
    • Comprehensive evaluation of the patient’s current functional status.
    • Utilization of a standardized assessment instrument to document findings.
  2. Development of Revised Plan:
    • Based on assessment results, the current care plan is reviewed and revised.
    • Goals and treatment strategies are adapted to accommodate the updated assessment.
    • New exercises, therapies, or adjustments to existing regimens are prescribed.

Duration

Approximately 30-60 minutes, depending on the complexity of the case.

Setting

Typically performed in an outpatient clinic, athletic training facility, or sports rehabilitation center.

Personnel

  • Certified Athletic Trainer
  • Physical Therapist (if necessary)
  • Physician (optional, for complex cases)

Risks and Complications

  • Minimal risks, as the procedure is non-invasive.
  • Potential for discomfort during functional testing.
  • Risk of further injury if new plan is not properly followed.

Benefits

  • Personalized and updated care plan based on the latest assessment.
  • Enhanced recovery and performance outcomes.
  • Immediate adjustments to training to prevent worsening condition.

Recovery

  • No specific recovery period is required.
  • Follow-up appointments may be scheduled to monitor progress.
  • Adherence to revised care plan is crucial for optimal outcomes.

Alternatives

  • Continued use of the existing plan without reassessment, which may not address current needs.
  • Seeking a second opinion from another healthcare provider.

Patient Experience

  • The patient may experience mild discomfort during functional assessments.
  • Reassurance and clear communication throughout the process help in managing any anxiety or discomfort.
  • Post-assessment, patients should feel equipped with a clearly defined and customized care plan for their rehabilitation.

Medical Policies and Guidelines for Re-evaluation of athletic training established plan of care requiring these components: An assessment of patient's current functional status when there is a documented change; and A revised plan of care using a standardized patient assessment instrument a

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