CPT® Code 96121

Add-On Code

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 professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure)

A neurobehavioral status exam is a clinical assessment conducted by a physician or other qualified healthcare professional to evaluate various cognitive functions and behaviors associated with brain health. This examination focuses on critical areas such as thinking, reasoning, and judgment, which are essential for daily functioning. The assessment encompasses a range of cognitive abilities, including acquired knowledge, attention, language skills, memory, planning, problem-solving capabilities, and visual-spatial skills. The underlying causes of brain dysfunction that may necessitate such an exam are varied and can include vascular or metabolic disorders, head injuries, infections, exposure to toxins, brain tumors, developmental disorders like autism spectrum disorders, and neurodegenerative conditions. The neurobehavioral status exam is particularly valuable as it can serve both as an initial diagnostic tool to identify and characterize brain dysfunction and as a follow-up measure to monitor the progression of symptoms over time. During the exam, the healthcare professional engages in extensive observation and evaluation of the patient's behavior and cognitive development, often without relying on direct testing instruments. After completing the assessment, the professional interprets the findings and prepares a comprehensive report detailing the results. For billing purposes, CPT® Code 96116 is utilized for the first hour of the exam, while CPT® Code 96121 is designated for each additional hour of assessment and report preparation.