Treatment for autism with ABA therapy (Applied Behavioral Analysis therapy) has come a long way. The billing and coding have also changed significantly in the last ten years. The initial medical billing codes were undefined, leading to unreliable coverage and reimbursement.
To create a standardized set of ABA CPT codes, the American Medical Association (AMA) established temporary Category III codes that went into effect mid-2014. The Steering Committee for the ABA Services workgroup consisted of ABAI, APBA, Autism Speaks, and the BACB, who researched the copious feedback from utilizing the Category III code set. This leads the ABA workgroup to prepare and submit the proposed code changes to the CPT Editorial Panel. The panel approved eight Category I CPT codes for Adaptive Behavior Services that went into effect on January 1, 2019.
Understanding Category I CPT Billing Codes
It is essential that your billing and clinical staff have a clear understanding of the Category I ABA medical codes for billing to accurately document and bill for services. Training and consistent implementation of policies will help ensure that accurate billing is submitted. There are excellent resources to obtain a better understanding of the ABA billing codes. The ABA Coding Coalition was developed to work with payers on the established CPT codes and for ongoing review and updates as needed. Great information, including full explanations of each code can be located on their website at https://abacodes.org/.
Professional ABA membership organizations are also an excellent resource for understanding ABA-specific medical code billing, such as:
- Association for Behavior Analysis International (ABAI) and local state chapters of ABAI — https://www.abainternational.org/welcome.aspx
- Association of Professional Behavior Analysts (APBA) — https://www.apbahome.net/
- Council on Autism Service Providers (CASP) — https://casproviders.org/
- Behavior Analysis Certification Board (BACB) — https://www.bacb.com/
- Autism Law Summit — https://autismlawsummit.com/
Understanding the Categories
Adaptive Behavior Assessment
Code 97151
In terms of the first category of ABA therapy CPT codes, 97151 is used for the initial behavior identification assessment. This covers time spent working face-to-face with patients, guardians, and/or caregivers to discuss findings or recommendations. It also includes any time spent working outside of interactions with the patient to analyze past data, score or interpret the assessment, and prepare the treatment plan. Beginning in 2019, all CPT codes cover increments of 15 minutes. This differs from the previous codes, which were used to refer to either untimed sessions or 30-minute increments.
Code 97152
Code 97152 is used for behavior identification supporting assessments. These are conducted by a single technician under the direction of a qualified healthcare professional during face-to-face sessions with the patient. Patients who exhibit destructive behavior may need to be observed under the care of two or more technicians in a specialized environment. In this case, the Category III code 0362T is used.
Adaptive Behavior Treatment
Code 97153
When referring to a specific treatment, code 97153 is used for adaptive behavior treatment administered by a technician under the direction of a physician or other qualified professional. For patients who exhibit destructive behavior that calls for more specialized treatment with protocol modification, the Category III code 0373T is used.
Code 97154
Group adaptive behavior by protocol is identified by code 97154. A technician administers treatment under the direction of a physician or other qualified professional. This is face-to-face with at least two patients.
Code 97155
Code 97155 covers adaptive behavior treatment provided by a professional, which may include the simultaneous direction of a technician. This is a face-to-face treatment with one patient.
Code 97156
Family adaptive behavior treatment guidance falls under code 97156. A physician or other qualified professional administers this treatment, which is face-to-face with the guardian or caregivers. The presence of the patient is not required.
Code 97157
Code 97157 refers to these services provided in a multiple-family setting. A physician or other qualified professional administers this treatment, which is face-to-face with multiple sets of guardians or caregivers. The patient must not be present.
Code 97158
Group treatments that feature protocol modification use code 97158. A physician or other qualified professional administers this treatment, which is face-to-face with multiple patients.
Need More Assistance on ABA Guidelines and Billing?
Confused about where to begin? At Missing Piece Billing and Consulting, we offer comprehensive revenue cycle management that includes provider education. Explore the advantages of ABA practice management software for convenience when implementing a medical billing code, as well as the expectations when outsourcing ABA insurance and billing.
Contact us today to schedule your free billing analysis at 765-628-7400 or weare@yourmissingpiece.com. You can also reach out to us here to find out more about the service we offer and how we can assist.