CMS Proposes Rules for Calendar Year 2023 Pricing and Telehealth Approval Status of CPT Codes for ABA Services

August 16, 2022

Recently the Centers for Medicare & Medicaid Services (CMS) published the proposed Medicare Physician Fee Schedule (MPFS) and proposed rule changes for 2023. The agency is proposing that the CPT codes for adaptive behavior/ABA services (97151 – 97158, 0362T, 0373T) remain carrier-priced throughout 2023, as they have been since they went into effect January 1, 2019.

CMS also proposes to change the categorization of the CPT codes for ABA services on the Medicare list of services/codes for which payment for telehealth delivery is approved. Those codes had been added to the Medicare telehealth list on an interim basis for the duration of the federal COVID-19 public health emergency (PHE). Last June the ABA Coding Coalition submitted a request to CMS to place the codes for which we found research evidence of efficacious telehealth delivery (97151 – 97156) in Category 2, one of two permanent telehealth categories. In the proposed rules for 2023, CMS indicates that it is not inclined to make that change at this time. The agency does, however, propose to add the full ABA services code set (97151 – 97158, 0362T, 0373T) to its temporary telehealth Category 3. That will allow payment for telehealth delivery of those services through the end of 2023. The agency notes that although the services are likely to be beneficial when delivered by telehealth, “…more time may be necessary to develop evidence that could support the decision to add these services to the Medicare Telehealth Services List permanently on a Category 1 or Category 2 basis.” They express concerns as to whether telehealth delivery of the services can be done in a way that does not jeopardize patient care and safety, and whether patient behaviors can be assessed fully via audio-video technology. The Coding Coalition has written to CMS to say that our review of research indicates that codes 97151 – 97156 can be delivered safely and effectively via telehealth to certain patient groups, and to urge them to re-review our application to have those codes approved for telehealth permanently on a Category 2 basis.

The entire (very large) set of proposed MPFS rules can be accessed here. Public comments may be submitted through September 6, 2022 via a button on that website or by other means listed there under “Addresses.” We emphasize that the rules are proposed. The final MPFS will be released on or around November 1, 2022. We will review it carefully and apprise our constituents of relevant final rules.