CPT® Code 0360T

Deleted

1. Indications

The observational behavioral follow-up assessment is indicated for patients exhibiting specifically identified maladaptive or destructive behaviors. These behaviors may include:

• Aggression - Behaviors that may involve physical or verbal hostility towards others.
• Self-harm - Actions that result in injury to oneself, which may require monitoring and intervention.
• Property destruction - Behaviors that involve damaging or destroying property, indicating a need for behavioral assessment and management.
• Social or communication deficits - Challenges in social interactions or communication that may contribute to maladaptive behaviors.

2. Procedure

The procedure for conducting an observational behavioral follow-up assessment involves several key steps, which are detailed as follows:

• Step 1: Preparation - Prior to the assessment, the technician reviews the patient's treatment plan and any previous assessments to understand the specific behaviors that need to be monitored. This preparation ensures that the technician is equipped with the necessary context to conduct an effective assessment.
• Step 2: Face-to-Face Interaction - The technician engages in a face-to-face interaction with the patient for the first 30 minutes. During this time, the technician observes the patient's behavior in a natural setting, such as their home or school, to gather real-time data on their interactions and responses.
• Step 3: Structured Observation - The technician conducts structured observations or testing, focusing on key areas of adaptive behavior, including cooperation, expressive speech, requests, social interactions, and motivation. This structured approach allows for a comprehensive evaluation of the patient's behavior.
• Step 4: Documentation - Throughout the assessment, the technician meticulously documents all observations and data collected. This documentation is crucial for providing a clear record of the patient's behavior and the effectiveness of the treatment strategies in place.
• Step 5: Reporting - After the assessment, the technician compiles the findings and reports them to the supervising physician or qualified health care professional. This report includes an interpretation of the data and any notable observations made during the assessment.
• Step 6: Feedback Discussion - The physician or qualified health care professional reviews the report and engages in a feedback discussion with the primary caregiver(s). This discussion includes recommendations based on the assessment results, aimed at improving the patient's treatment plan and addressing any ongoing behavioral concerns.

3. Post-Procedure

Post-procedure care following the observational behavioral follow-up assessment involves several considerations. The technician's documentation and the physician's report serve as a foundation for ongoing treatment planning. Caregivers are encouraged to implement any recommendations provided during the feedback discussion to enhance the patient's behavioral management strategies. Additionally, follow-up assessments may be scheduled as needed to monitor progress and make necessary adjustments to the treatment plan. Continuous communication between the technician, physician, and caregivers is essential to ensure that the patient receives the most effective support and intervention for their behavioral challenges.