Adaptive Behavior Services/Applied Behavior Analysis (ABA) Billing Standard Version 3.1

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Contents

General

Purpose

Applicability

Basic Concepts

Definitions

Detail

Implementation

History

Appendix A – Code Crosswalk

 

General

The UHIN Standard Adaptive Behavior Services/ABA Billing Standard is compatible with all HIPAA requirements.

Purpose

Utah legislation S.B.57 of the 2014 General Session requires eligible payers to provide health benefit plan coverage for the treatment of autism spectrum disorder. These services include ABA treatment. The purpose of this UHIN Standard is to detail the billing for the transmission of ABA services in the State of Utah. [1]

Applicability

This Standard applies to all Adaptive Behavior Services (i.e. ABA) claims. This includes primary, secondary and tertiary claims.

Basic Concepts

The usage of the codes provided in this standard meets with the services rendered by the health care professional, that fall within the scope of services defined by 2015 S.B. 246 / Utah Code 58-61-7 and sanctions consistent billing to payers. Streamlined Coordination of benefits is an additional benefit of standardizing the procedure codes for these services.

Definitions

Qualified Health Professional (QHP):

These are providers that are working within the scope of their licensure within the State of Utah, including those who are licensed under Utah Code 58-1-7 or are exempted from licensure under Utah Code 58-61-707 subsections 10-12.

Technicians referenced within the code table below are providing services under the supervision of the QHCP and may not be independently licensed.

Billing Codes:

  • Temporary codes: Temporary codes are for the purpose of meeting, within a short time frame, the national program operational needs of a particular insurance sector that are not addressed by an already existing national code. Temporary codes do not have established expiration dates.

When permanent codes are established by the AMA those codes will be incorporated within the standard and will replace any temporary codes identified.

  • Permanent Codes: These codes are for the use of all private and public health insurers.
  • Code Modifiers: provide additional information regarding the service or item identified by the procedure code.
  • Unit of Time: Unit of time is attained when the mid-point is passed. Refer to the CPT Code hand book (footnote) for appropriate billing of codes with units of time identified.

Detail

Providers will use the following codes for billing Adaptive Behavior Services (i.e. ABA services) rendered. Some of the codes used in this standard are temporary codes and may be revised when and if a permanent code is developed as a replacement for these services.

Assessment for Treatment Plan Development – Initial and Periodic Re-assessment

Essential Elements of Applied Behavior Analysis Services:[2]

Development of individualized treatment plan by supervising behavior analyst/QHP.  Assessment may include:

  • review of file information about client’s medical status, prior assessments, prior treatments;
  • stakeholder interviews and rating scales;
  • review of assessments by other professionals;
  • direct observation and measurement of client behavior in structured and unstructured situations;
  • determination of baseline levels of adaptive and maladaptive behaviors;
  • functional behavior analysis.

Code[3]

Descriptor

Attended By

Time/Units

Comments

97151

Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.

Client, QHP

per 15 min

May be followed by 97152 or 0362T

97152

Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes.

client, technician (QHP may substitute for the technician)

per 15 min

 

Functional Analysis of Severe Maladaptive Behaviors in Specialized Settings

Code

Descriptor

Attended By

Time/Units

Comments

0362T

 

Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:

  • administered by the physician or other qualified healthcare professional who is on site[4];
  • with the assistance of two or more technicians;
  • for a patient who exhibits destructive behavior;
  • completed in an environment that is customized to the patient’s behavior.

Client and 2 or more technicians; QHP on site

per 15 min

 

             

 

Direct Treatment

Essential Elements of Applied Behavior Analysis Services:

Implementation and management of treatment plan by supervising behavior analyst/QHP. Includes:

  • Training technicians to
    • carry out treatment protocols accurately, frequently, and consistently;
    • record data on treatment targets;
    • record notes;
    • summarize and graph data.
  • Training family members and other caregivers to implement selected aspects of treatment plan.
  • Ongoing supervision of technician and caregiver implementation.
  • Ongoing, frequent review and analysis of direct observational data on treatment targets.
  • Modification of treatment targets and protocols based on data.
  • Training technicians, family members, and other caregivers to implement revised protocols.

Code

Descriptor

Attended By

Time/Units

Comments

97153

Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes.

Client, Technician

per 15 min

If QHP is directing the technician without the client present, this is a bundled service and is captured by the codes above and below. If the QHP4 is directing a technician or caregiver with the client present, report using the 97155 code below. 97155 may be reported concurrently with technician delivered services 97153 when the patient is present, one or more protocols have been modified, and the QHP is directing the technician.

Responsibilities required for this task include indirect work completed by the QHP and/or Technician before (e.g., selection of treatment targets, collaboration with family members and other stakeholders, training Technician, creating materials, gathering materials, reviewing data) and after (e.g., entering and analyzing data, revising protocols) the direct service by the Technician.

 

 

Direct Treatment of Severe Maladaptive Behavior in Specialized Settings

Code

Descriptor

Attended By

Time/Units

Comments

0373T

Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:

  • administered by the physician or other qualified healthcare professional who is on site5;
  • with the assistance of two or more technicians;
  • for a patient who exhibits destructive behavior;
  • completed in an environment that is customized, to the patient’s behavior.

 Client and 2 or more Technicians; QHP on site

per 15 min

 

 

Direct Treatment by QHP

Code

Descriptor

Attended By

Time/Units

Comments

97155

Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.

Client, QHP, may include technician and/or caregiver

per 15 min

May include demonstration, observation and direction of implementation and modification of protocol. May include technician(s), caregiver(s), and client.

If QHP is directing the technician without the client present, this is a bundled service and is captured by the codes above and below. If the QHP is directing a technician or caregiver with the client present, 97155 may be reported concurrently with technician delivered services 97153 or 97154 when the patient(s) is present, one or more protocols have been modified, and the QHP is directing the technician.

Responsibilities required for this task include indirect work completed by the QHP before (e.g., selection of treatment targets, collaboration with family members and other stakeholders, creating materials, gathering materials, reviewing data) and after (e.g., entering and analyzing data, revising protocols) the direct service by the QHP.

Group Treatment

Code

Descriptor

Attended By

Time/Units

Comments

97154

Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes.

2 or more clients, Technician (QHP may substitute for technician)

per 15 min

 

97158

Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes.

2 or more clients and QHP

per 15 min

 

Family Training

Code

Descriptor

Attended By

Time/Units

Comments

97156

Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.

Caregiver and QHP

per 15 min

With or without client present

97157

Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.

Caregivers of 2 or more clients and QHP

per 15 min

Caregivers of 2 or more clients, Without the client present

             

 

Implementation

Provider:

When billing a national payer not subject to UID Uniform Billing Rule 590-164, providers may need to create/utilize a crosswalk for the procedure codes. (Crosswalk examples can be found in Appendix A)

Providers will need to understand what services and types of providers are allowed to be billed to each payer.

Providers may see claims denied as a non-qualified provider when in fact it is the service that is not a covered benefit. In this instance, the provider should work with the payer to have a corrected denial that indicates the service is the issue not the provider.             

Payers:

Those payers that are subject to UID Uniform Billing Rule 590-164 are required to accept all codes represented in this standard that are sent in a claim from the appropriate provider.

Payers may not pay all provider types; it is the responsibility of the provider to know what provider types are eligible to provide services for each payer.

When a payer receives a claim for an out-of-network service, (e.g. closed PPO) it is recommended that the denial address the service and not the provider. This will streamline the COB process and allow the secondary payer to pick up the services when the primary payer does not provide a benefit.

History

 

Original

V3.1

 

ORIGINATION DATE

9/14/2016

12/20/2018

 

APPROVAL DATE

5/3/2017

1/2/2019

 

EFFECTIVE DATE

6/3/2017

2/2/2019

 

 

 

Appendix A – Code Crosswalk

The intent of the crosswalk is to facilitate the transition between temporary codes and permanent codes. However, there will be cases in which the temporary HCPCS codes are related to multiple permanent codes; in this case, the descriptors must be examined to determine the appropriate permanent code.

Code

Descriptor

HCPCS Code(s)

Assessment for Treatment Plan Development – Initial and Periodic Re-assessment

97151

Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.

H0031, H0032, 96150, 96151, G8539, 99347, H2019, H2020, 90899, S9480, 99499

Retired T Code:  0359T

97152

Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes.

H0031, H0032, 96150, 96151, G8539, 99347, H2019, H2020, 90899, S9480, 99499

Retired T Codes:  0360T and 0361T 

Functional Analysis of Severe Maladaptive Behaviors in Specialized Settings

0362T

 

Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:

  • administered by the physician or other qualified healthcare professional who is on site;
  • with the assistance of two or more technicians;
  • for a patient who exhibits destructive behavior;
  • completed in an environment that is customized to the patient’s behavior.

H2019, H2020, 90899, S9480, 99499, H0031, H0032, 99347, 96150, 96151, G8539

Retired T Code:  0363T

Direct Treatment

97153

Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes.

H2019, H2020, 90899, S9480, 99499, 96152, 96153, 96154, 96155, 99347, G8539, T1016

Retired T Codes:  0364T and 0365T

Direct Treatment of Severe Maladaptive Behavior in Specialized Settings

0373T

Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:

  • administered by the physician or other qualified healthcare professional who is on site;
  • with the assistance of two or more technicians;
  • for a patient who exhibits destructive behavior;
  • completed in an environment that is customized, to the patient’s behavior.

H2019, H2020, 90899, S9480, 99499, H0031, H2012, 96152, 96153, 96154, 96155, 99347, G8539, T1016

Retired T Code:  0374T

Direct Treatment by QHP

97155

Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.

H2012, H2019, 96152- 96155, G9012, H0032, 99080, 90887, S5108, S5110, S5115, G8542

Retired T Codes:  0368T, 0369T, 0360T*, and 0361T*

*TRICARE

Group Treatment

97154

Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes.

H2014, H2020

Retired T Codes:  0366T and 0367T

97158

Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes.

H2014, H2020

Retired T Code:  0372T

Family Training

97156

Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.

S5110, S5111

Retired T Code:  0370T

97157

Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.

S5110, S5111

Retired T Code:  0371T

 

 

[1] S.B.57 can be found at https://le.utah.gov/~2014/bills/static/sb0057.html

[2] Source: Behavior Analyst Certification Board (2014). Applied Behavior Analysis Treatment for Autism Spectrum Disorders: Guidelines for Healthcare Funders and Managers. Littleton, CO: Author. Available at http://bacb.com/asd-practice-document/

[3] All payers utilized some combination of HCPCS codes prior to the development of the Category III CPT® code set to report ABA services. Some payers continue to use HCPCS codes for this purpose.

[4] “On site” is defined as immediately available and interruptible to provide assistance and direction throughout the performance of the procedure; however, the physician or other qualified healthcare professional does not need to be present in the room when the procedure is performed.

 

 

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