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Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professio

CPT4 code

Neurobehavioral Status Exam

Name of the Procedure:
  • Common Name(s): Neurobehavioral Status Exam
  • Technical Term(s): Clinical assessment of thinking, reasoning, and judgment
Summary

A neurobehavioral status exam is a comprehensive evaluation performed by a healthcare professional to assess a patient's cognitive functions, including acquired knowledge, attention, language, memory, planning, problem-solving, and visual-spatial abilities. This exam helps identify any cognitive impairments or decline.

Purpose
  • Medical Condition: Cognitive impairment due to conditions such as dementia, traumatic brain injury, stroke, or psychiatric disorders.
  • Goals: To diagnose and document cognitive strengths and weaknesses, guide treatment planning, and monitor changes over time.
Indications
  • Symptoms such as memory loss, confusion, difficulty concentrating, language difficulties, or changes in behavior.
  • Patients who have experienced brain injuries, strokes, or who are suspected of having neurodegenerative conditions like Alzheimer's disease.
Preparation
  • Patients should bring a list of current medications.
  • No specific physical preparation like fasting is required.
  • Preliminary diagnostic tests such as brain imaging may be recommended.
Procedure Description
  1. Interview: The healthcare professional gathers a detailed patient history and reviews any symptoms.
  2. Assessments: A series of standardized tests and questionnaires are administered to evaluate different cognitive functions:
    • Attention: Tasks that measure the ability to focus and sustain attention.
    • Memory: Tests involving recall of words, stories, or visual information.
    • Language: Evaluations of naming, comprehension, and verbal fluency.
    • Executive Functioning: Problem-solving tasks and planning exercises.
    • Visual-Spatial Abilities: Tests that assess how well the patient understands visual and spatial relationships.
  3. Observation: The examiner observes the patient's behavior and interaction during the assessment.
  • Tools: Pen and paper, computerized tests, and structured interview forms.
  • Anesthesia/Sedation: Not applicable.
Duration

The procedure typically takes 1-3 hours, depending on the extent of testing required.

Setting
  • The exam is usually conducted in a hospital, outpatient clinic, or specialized neuropsychology office.
Personnel
  • The exam is administered by a physician, neuropsychologist, or other qualified healthcare professionals with training in neurobehavioral assessment.
Risks and Complications
  • Common Risks: Minimal, with no physical risks involved.
  • Rare Risks: Psychological distress if the patient becomes anxious or upset during testing.
Benefits
  • Expected Benefits: Accurate diagnosis of cognitive impairments, aiding in the design of effective treatment and management plans.
  • Timeframe: Results and recommendations are typically available within a few days to a week after the exam.
Recovery
  • Post-Procedure Care: Not applicable as no physical recovery is needed.
  • Follow-up: Follow-up appointments may be scheduled for discussing results and planning further treatment.
Alternatives
  • Other cognitive assessment tools or scales.
  • Pros and Cons: While other tools may be quicker or less comprehensive, the neurobehavioral status exam provides a detailed and thorough evaluation.
Patient Experience
  • During the Procedure: The patient may feel a range of emotions, from curiosity to frustration, depending on the difficulty of the tasks.
  • After the Procedure: Patients may feel tired due to the mental effort but no physical pain. Comfort measures, including breaks during the exam, are typically provided.

Medical Policies and Guidelines for Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professio

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