Balance Error Scoring System (BESS) 

The Balance Error Scoring System (BESS) is a clinical test of postural stability that scores balance errors across three stances (double-leg, single-leg, tandem) performed on a firm surface and a foam pad, eyes closed, for 20 seconds each. It is a standard component of concussion assessment, most sensitive in the first 24–72 hours post-injury, and is best interpreted against an individual's own preseason baseline rather than a fixed population cutoff.

What BESS Measures

BESS quantifies postural control — the body's ability to maintain balance using visual, vestibular, and somatosensory input — by removing vision (eyes closed) and, on the foam condition, degrading somatosensory feedback from the feet. This combination stresses the vestibular and proprioceptive systems that are commonly disrupted after a concussion, making BESS one of the balance-focused tools embedded in standard sideline and clinic concussion batteries such as the SCAT5/SCAT6 (opens in a new tab) consensus tools.

The test does not diagnose concussion on its own. It is one data point — postural stability — that is combined with symptom report, cognitive screening, and clinical judgment to characterize recovery.

Administration

BESS consists of six 20-second trials, performed in this order:

1. Double-leg stance, firm surface — feet together, hands on hips, eyes closed
2. Single-leg stance, firm surface — standing on the non-dominant leg
3. Tandem stance, firm surface — non-dominant foot directly behind the dominant foot, heel-to-toe
4. Double-leg stance, foam surface
5. Single-leg stance, foam surface
6. Tandem stance, foam surface

Total administration time is approximately 5–7 minutes including setup and instructions. The examiner counts errors during each 20-second trial — moving the hands off the hips, opening the eyes, stepping, stumbling or falling, lifting the forefoot or heel, abducting the hip more than 30 degrees, or remaining out of the test position for more than 5 seconds.

Scoring and Interpretation

Each trial is capped at a maximum of 10 errors, and the total BESS score is the sum of errors across all six trials, producing a range of 0 to 60. A higher total indicates worse postural stability.

There is no single, universally validated cutoff that separates "normal" from "abnormal" BESS performance. In most protocols, scores are interpreted by comparing a post-injury total against the athlete's own preseason baseline score rather than against a fixed population threshold, because normal balance performance varies with age, athletic background, fatigue, footwear, and even the specific foam pad and testing surface used. Test-retest variability and practice effects are also well documented, which is why baseline testing programs matter for accurate interpretation — see Baseline Testing Programs.

BESS sensitivity is highest acutely. Performance commonly normalizes within several days post-injury even when other symptoms persist, so a normal BESS score at a later follow-up visit does not rule out ongoing concussion-related impairment. For that reason BESS is typically weighted most heavily in the acute evaluation window and used alongside other tools — such as VOMS for oculomotor/vestibular screening and the PCSS for symptom tracking — for the fuller clinical picture during follow-up.

Clinical Use Case

BESS is used at multiple points in concussion management:

• Sideline/acute evaluation — as part of a broader assessment (often alongside the SAC and symptom checklist) to characterize the acute injury.
• Baseline testing — administered preseason in athletic populations so a true within-individual comparison is possible after injury.
• Serial monitoring during recovery — repeated at follow-up visits to track whether postural stability is trending back toward baseline, informing return-to-play and return-to-learn decisions alongside symptom and cognitive data.
• Persistent symptom evaluation — when balance complaints persist beyond the expected window, an abnormal BESS can help justify referral for formal vestibular rehabilitation; see Vestibular Rehab at Home and Managing Persistent Post-Concussive Symptoms.

Billing Context

BESS is a brief, examiner-administered clinical maneuver rather than a formal standardized psychometric battery, so it is typically bundled into the evaluation and management (E/M) visit or sideline/urgent encounter rather than billed separately under the neuropsychological or psychological testing code family (96116–96146). When BESS is captured as part of a broader between-visit monitoring program that also includes patient-reported outcome instruments and cognitive testing, the monitoring activity itself — time spent reviewing data, interactive communication with the patient, and device-based data collection — may support Remote Therapeutic Monitoring billing under codes such as 98978 and 98980/98981. Actual code assignment depends on who performs the assessment, the setting, and payer-specific policy; verify current requirements before billing. See the general neurocognitive testing billing overview for how BESS fits alongside billable standardized testing.

Where BESS Sits in the Kavera Protocol

Within Kavera's assessment battery, BESS-type postural stability data is one input among the symptom, mood, sleep, and cognitive-domain instruments delivered as part of the Concussion module. It is most useful early in the care pathway and during serial follow-up, complementing tools like the PCSS and cognitive-domain tests such as the Trail Making Test A that track other aspects of recovery.

FAQ

What is a "good" BESS score?

There is no fixed universal cutoff. In most protocols, a post-injury BESS score is compared against the individual's own preseason baseline; an increase from baseline suggests worse postural stability, but the absence of a change does not rule out concussion.

How long does the BESS take to administer?

Approximately 5–7 minutes for all six 20-second trials, plus instructions and setup time.

Is BESS the same as the mBESS used in SCAT5/SCAT6?

The modified BESS (mBESS) used in sideline tools like SCAT5/SCAT6 typically uses only the firm-surface trials (omitting the foam-pad conditions) for practicality. Full BESS includes all six trials on both surfaces. Confirm which version a given protocol specifies before comparing scores across settings.

Can BESS alone diagnose a concussion?

No. BESS measures one domain — postural stability — and should be interpreted alongside symptom report, cognitive testing, and clinical judgment, not as a standalone diagnostic test.

Is BESS separately billable under CPT?

Generally no — it is typically bundled into the E/M or sideline evaluation rather than billed under the 96116–96146 testing code family. See CPT 96116 for related billing guidance and consult current payer policy.

How Kavera Handles This

BESS is administered in the room at the first visit and re-evaluation; Kavera stores the score with the rest of the concussion baseline so vestibular change is tracked alongside symptoms and cognition. Between visits, VOMS and PCSS carry the vestibular and symptom signal through weekly check-ins. Self-Serve practices run this with their own staff. On Managed, Juliet Mott's team runs it and bills it under your credentials.