TRICARE has several changes in store for ABA patients and providers in 2021. To view the full list of what’s new to TRICARE, visit here.
As part of the Extended Care Health Option (ECHO), members are now eligible for the Autism Care Demonstration program. Beginning October 1, 2021, TRICARE will assign an autism-specific care manager, known as an ASN, to new members in the ECHO program. This representative will be the primary advocate for the patient.
Contracting with TRICARE will also be updated. Effective July 1, 2021, all providers will be required to bill with a NPI including Registered Behavioral Technicians or RBTs. Additionally, centers or clinics must re-sign all the participation agreements by August 1, 2021, and background checks will be required to be submitted as part of the enrollment process. By October 1, 2021, providers will be required to attend provider education training at least annually.
Effective May 1, 2021, TRICARE will no longer be authorizing school-based services rendered by RBTs. Existing authorizations with approved school-based services will be allowed to continue for the duration of the authorization period.
TRICARE will continue to require treatment reviews every six months prior to authorization services. These reviews will require the following:
- Baseline
- Treatment Plan with goals, targets, and recommended hours for each code
- PDD-BI, Parent Form
- Vineland Adaptive Behavior Scales-2 (Vineland-3), The Parent Form, The Interview Form or the Teacher form are required.
- Social Responsiveness Scale (SRS-2), The Parent Form is required.
- Parenting Stress Index, the Parent form is required; or Stress Index for Parents of Adolescents (SIPA), The Short Form is required.
- Every six months
- Treatment Plan with goals, targets, and recommended hours for each code
- PDD-BI, Parent and Teacher Form completed by BCBA/BCBA-D
- Parenting Stress Index, the Parent form is required; or Stress Index for Parents of Adolescents (SIPA), The Short Form is required.
- Annually (in addition to six-month requirements)
- Social Responsiveness Scale (SRS-2), The Parent Form is required.
- Vineland Adaptive Behavior Scales-2 (Vineland-3), The Parent Form, The Interview Form or the Teacher form are required.
Code Changes:
- Increase in allowed units for 97151 from 16 units to 32 units for initial evaluation, and up to 24 units for ongoing evaluations. For the initial evaluation, TRICARE will continue to require that all units must be used within 14 calendar days from the first date of service.
- Discontinuing code T1023, which will now be billed as 97151.
- New group codes allowed 97157 for Multiple Family Group Adaptive Behavior Treatment Guidance and 97158 for Group Adaptive Behavior Treatment by Protocol Modification. Both codes will be effective August 1, 2021 and allow up to 8 group members and 6 units per day.
- New Medical Team Conference Codes 99366 for Medical Team Conference with Patient by a healthcare professional and 99368 Medical Team Conference without Patient by healthcare professional will be allowed effective August 1, 2021. Both codes allow in person or telehealth for the conference, including the TRICARE ASN or Care manager, and at least 3 QHPs from different specialties or disciplines who provide direct care for the patient.
Concurrent billing for ABA therapy is excluded for all ACD Category I CPT codes except when the family and patient are receiving separate, distinct services and the patient is not present in the parent/caregiver sessions. For example, if the patient receives direct therapy CPT code 97153 with an RBT at the clinic, the parent may participate in Multiple Family Group Adaptive Behavior Treatment Guidance CPT code 97157 at the clinic in a separate location from the patient, and these services may be simultaneously billed.
Additionally, Adaptive Behavior Treatment with Protocol Modification (code 97155) must be completed at least once monthly. If this requirement is not met, the provider may be subject to a penalty of 10% recoupment for the entire period of the authorization.
TRICARE has extremely stringent policies and procedures for ABA therapy, and these are continually updated. It is imperative that providers who render services to TRICARE beneficiaries become very familiar with the policies and continually review them for updates.
This blog provides a summary of updates, but should not be utilized as a comprehensive, detailed policies review or training. Please refer to the TRICARE website and the TRICARE Operations Manual for complete information.
Want help sorting out all the updates for TRICARE and other payers, contact Missing Piece Billing and Consulting to help you pull all the pieces together.
Contact us today for your free consultation at 765-628-7400 or weare@yourmissingpiece.com.
References:
Department Of Defense (DoD) Comprehensive Autism Care Demonstration (ACD)