Advocacy Efforts

Members of the ABACC have been working with the Centers for Medicare and Medicaid Services (CMS) to establish appropriate medically unlikely edits (MUEs) for billing codes for adaptive behavior services. An MUE is the maximum number of units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. MUEs are set by an agency contracted by CMS called the National Correct Coding Initiative (NCCI), and are intended to reduce the paid claims error rate for Medicare claims. Although third-party payers are not required to follow the MUEs established by CMS, many incorporate them in their claims processing systems and policies.

When the MUEs for the 2019 CPT^® codes for adaptive behavior services were released in December 2018, the former steering committee for ABA services (described in the “About Us” section) asked CMS to revise several of the proposed MUEs. CMS agreed to most of those requests, but for code 97151, CMS changed the Medicaid MUE to 32 units (8 hours) per day and left the Medicare MUE for that code at 8 units (2 hours). CMS publishes only the Medicare MUEs on its website, and many payers use the Medicare MUEs. A copy of the December 13, 2018 letter from NCCI is available here. The table that follows represents the Medicare MUEs that were released July 1, 2019, which can also be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

The ABACC submitted requests to CMS for additional changes in MUEs for the adaptive behavior services codes, specifically to make the Medicare MUE for code 97151 the same as the Medicaid MUE and to increase MUEs for codes 97154 and 97155. The CMS responded that because the code set is new, they declined to make further changes in the MUEs until more data on typical utilization of the codes are available. The ABACC plans to collect information from providers to support future requests for modifications in MUEs. Updates and additional resources on MUEs will be posted on this website; ABACC member organizations will also apprise their constituents via email and social media. Providers who wish to appeal denied claims based on MUEs should visit the CMS website for guidance, and be prepared to include in their appeal rationale and evidence that daily service units higher than the MUE are medically necessary for the client in question.

July 2020 Update – CMS publishes two separate MUE data files each quarter containing the MUEs for all healthcare billing codes, one for Medicare and one for Medicaid. These two data files sometimes provide discrepant MUE values for a given CPT code. For instance, for CPT code 97151 the current Medicare MUE is 8 units per day, whereas the Medicaid MUE is 32 units per day. Of these two MUE values, the one published by Medicaid is clearly the more appropriate MUE for the 97151 code.

Many payers adopt the Medicare MUEs, but because the vast majority of the patients served by ABA providers at this time are Medicaid rather than Medicare beneficiaries, the Medicaid MUEs are more appropriate for the CPT codes for adaptive-behavior (ABA) services. Therefore, the ABA Coding Coalition urges providers and payers to become familiar with and adopt the Medicaid MUE values assigned to the adaptive-behavior service codes. The current MUEs for a specific code can be found here by entering the code in the search box that says, “Find in this Dataset”. Our coalition will continue to advocate with CMS to increase Medicare MUEs for the adaptive-behavior-service codes that are overly restrictive, and we will provide updates regarding these MUEs as they become available.

December 2020 Update #1 – After receiving reports from providers that many health plans are utilizing the Centers for Medicare & Medicaid (CMS) MEDICARE values for Medically Unlikely Edits (MUEs) to set per-patient per-day limitations on ABA services, the ABA Coding Coalition made a request of payers nationwide to utilize the CMS MEDICAID MUEs, which allows increased units of service for assessment code 97151 and destructive behavior code 0373T. This recommendation is consistent with our Model Coverage Policy for Adaptive Behavior Services. For more information on MUEs, click here.

December 2020 Update #2 – The ABA Coding Coalition successfully advocated with the National Correct Coding Initiative for several INCREASES to Medicare MUEs, which take effect on January 1, 2021! The increases are for the following codes:

The Coalition continues to advocate for increases to Medicare MUEs for 97151; however, we encourage providers to continue asking payers to use Medicaid MUEs, as noted in our update earlier this month. For more information on the 2021 MUEs, click here.

Autism Law Summit (October 2019)

Members of the ABA Coding Coalition participated in the annual Autism Law Summit in October 2019 in Jackson Hole, Wyoming. The Autism Law Summit is an annual national gathering of autism parents, providers, professionals, lawyers, legislators, researchers, and others interested in the policy and politics of autism. Participants share information about how best to utilize existing laws and regulations for the benefit of individuals with autism; attendees also brainstorm needed legal reforms and strategize about how to achieve such change. For more information, visit www.autismlawsummit.com.

Of particular note, members of the ABA Coding Coalition helped lead an interactive Payer Workshop that took place the day before the Summit. The Payer Workshop brought together national and regional insurance and Medicaid payers who are actively engaged in managing the payment of ABA claims with providers and billers who submit such claims. The Payer Workshop fostered open conversation and collaborative problem-solving on CPT^® coding issues and other payment matters.

Conference Presentations and Webinars

ABACC members have given presentations on the 2019 codes for adaptive behavior services and related topics at numerous state, regional, and national conferences as well as webinars hosted by several organizations. To request a presentation for providers, payers, or other interested parties, please contact the relevant Coalition member organization or the consultant directly, or use the Contact feature on this website.

Coalition Advocates for Changes in TRICARE Autism Care Demonstration Billing Code Policies

In March the Defense Health Agency (DHA), which manages the TRICARE Autism Care Demonstration (ACD) program, issued revised policies for that program. They included policies on billing with the CPT codes for adaptive behavior/ABA services that are inconsistent with the code descriptors and related documents published by the American Medical Association as well as the code authors’ intended use. The policies also excluded some codes and set restrictions and limitations on some services, including numbers of units authorized and telehealth delivery. In July the ABA Coding Coalition wrote to the Director of the DHA to offer clarifications and resources. We also requested changes in the policies to make them comport with the AMA-approved code descriptors, intended use of the codes (including implementation of the full 2019 code set), and Medicaid rather than Medicare Medically Unlikely Edits (MUEs). Having received no reply to that letter, the Coalition sent a followup letter to the DHA Director this month to ask when a reply to our July letter might be forthcoming and to reiterate our previous request for the DHA to allow telehealth delivery of certain ABA services to ACD beneficiaries. If we learn of any changes in the policies around the CPT codes, we will post announcements here and under Advocacy Efforts/Other Outreach to Payers.

Coalition Confirms ABA Providers May Use 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

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.

Coalition Prompts Louisiana Medicaid Policy Change

On receiving reports from Louisiana providers that the state Medicaid agency had implemented a policy requiring 10 minutes of service to be rendered before a unit of service could be billed with the adaptive behavior (ABA) services CPT codes, the ABA Coding Coalition asked Louisiana Medicaid to rescind the policy and replace it with the American Medical Association’s CPT® rounding rule, which allows a unit of service to be reported for time-based codes after the halfway point is reached — that’s 8 minutes for codes 97151-97158, 0362T, and 0373T because all are 15-minute codes. Here is Louisiana Medicaid’s letter indicating their agreement with the changes requested by the Coalition.

Coalition Receives Optum Clarification on Rounding Policy for ABA CPT Codes

In response to provider outreach, the ABA Coding Coalition contacted Optum/United Behavioral Health in late December to express concern over their proposed 2020 rounding policy regarding the ABA CPT® codes. Optum proposed to require that 10 minutes of services be rendered in order to report using any of those codes. In our letter to Optum we pointed out that that policy contradicts American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) guidance to use the midway point of a time-based code’s time increment for rounding purposes (see our letter for details about those rules). For the ABA codes the midway point is 8 minutes, based on the 15-minute-per-unit interval specified in the code descriptors. In response to our letter, Optum has rescinded their policy and issued an FAQ stating that they will follow the rounding guidance from the AMA and CMS. Providers should note that although Optum’s FAQ still states their opinion that conducting at least 10 minutes of services per unit is “best practice,” that is not a requirement. In addition, Optum has indicated that it will not deny claims for services where the midway point of a time-based code’s time increment has been surpassed. If you encounter claims processing difficulties with Optum/UBH related to its rounding policy, please contact us.

ABA Coding Coalition Writes Anthem re: Proposed Changes to Reimbursement Policies

The Coalition heard from providers in several states that Anthem was reducing reimbursement rates for CPT codes 97153 and 97155. Antitrust laws prohibit professional organizations like Coalition member the Association of Behavior Analysts (APBA) from negotiating reimbursement rates on behalf of their constituents, but nonprofit professional organizations generally are allowed to advocate regarding payer policies. Therefore, the APBA attorney was enlisted to help the Coalition craft a letter to Anthem leadership in IN, OH, and TX to request reconsideration of that payer’s policies on its implementation of codes 97153 and 97155. We specifically asked Anthem to continue allowing those codes to be billed concurrently and to compensate providers adequately for the work and time involved in delivering the services. We will update providers on any developments of which we become aware in those three states and others where Anthem does business.

Supplemental Guidance Widely Distributed to Payers

The former steering committee described in the About Us section sent its Supplemental Guidance article on the 2019 CPT® codes to 20 national payers. Providers are encouraged to use it and share it with their payers. Subsequently the ABACC has provided feedback and consultation to several payers on their implementation of the 2019 code set via letters, phone conversations, and emails, and will continue to do so as appropriate. Additionally, with the help of an experienced ABA health insurance biller, the ABACC is attempting to track payer implementation of the 2019 CPT®codes. That information, which will be updated as new information becomes available, is in the Payer Implementation Tracker document on our Resources webpage. Members of the Association of Professional Behavior Analysts can also access it and associated resources by logging in to www.apbahome.net, then going to Members Only > Health Insurance Coverage.