ABA Providers May Use the New 99072 CPT Code

Some ABA providers may be aware of the following new CPT code that was issued recently by the American Medical Association (AMA) CPT Editorial Panel, effective immediately (i.e., this month):

99072: Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease

The code was issued by the CPT Editorial Panel under expedited procedures for releasing codes to address emergent issues arising from the COVID-19 pandemic. It is to be used for reporting additional practice expenses involved in providing services to patients safely during that public health emergency.

The ABA Coding Coalition has been informed that some payers have declined to allow ABA providers to report code 99072, asserting that it is not an ABA code. The Coalition checked with the CPT Division of the AMA, and confirmed that the code is not specific to any professional specialty, treatment, or patient condition but is available for billing by any physician or other professional who meets the AMA’s definition of a qualified health care professional (QHP): “…an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service. These professionals are distinct from ‘clinical staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. Other policies may also affect who may report specific services.” Therefore, ABA providers who meet the QHP criteria may report CPT code 99072 as long as all of the required elements in the code descriptor are met. As with all billing codes, it is essential for ABA providers to educate themselves about the code descriptor and the conditions under which it may be reported. A summary can be found at the following link, where the Sept. 8, 2020 CPT Assistant guide with the full code descriptor and other vital information can be downloaded: https://www.ama-assn.org/practice-management/cpt/covid-19-coding-and-guidance. Note that although the code descriptor specifies that the service is to be rendered by “clinical staff” as defined above, the CPT Assistant article states (p. 2)

In the instance in which the noted clinical staff activities are performed by a physician or other qualified health care professional (eg, in practice environments without clinical staff or a shortage of available staff), the activity requirements of this code would be considered as having been met; however, the time spent should not be counted in any other time-based visit or service reported during the same encounter.

That is, the service may be rendered by a QHP if necessary. Providers should check with payers on requirements for reporting such instances on claims.

The Coalition recommends that ABA providers read and digest the information about CPT code 99072 in the Sept. 8, 2020 CPT Assistant, and if they can meet the requirements for reporting it, ask payers to add that code to their contracts, citing the information in this message. Note that the code descriptor will have to be manually entered into EHR systems for now, which may take some time.