Frequently Asked Questions

GENERAL QUESTIONS

Q:  What is the difference between Category I and III codes?

Category III CPT codes

  • are temporary and for new or emerging services, so some payers do not adopt them while others impose their own definitions and interpretations.
  • signify only that there is some evidence of clinical efficacy and of “evolving clinical utilization”

Category I CPT codes

  • are permanent
  • signify that
    • the clinical efficacy of the services has been documented in research that meets rigorous AMA standards
    • The services are performed by many physicians or other qualified healthcare professionals and are consistent with current medical practice
  • Other benefits of Category I codes
    • More uniform and consistent adherence to the descriptors as approved by the CPT Editorial Panel
      • Fewer denials of coverage for ABA services on the false premise that they are “experimental,” “unproven,” or “not medically necessary.”

Q: What are the major differences between the 2019 CPT codes and the 2014 Category III codes?

  1. No add-on codes
  2. All codes are uniform time increments – 15 minutes per unit
  3. Concurrent billing with certain code pairs is clearly denoted in educational materials
  4. Social skills code has been replaced with group treatment codes
  5. Family training with QHP is “with or without patient present”
  6. Assessment codes have been streamlined and clarified. 97151 is for initial and reassessment by QHP. Supporting assessments may follow.
  7. “Exposure” codes have been revamped and clarified to specify that they are for functional analysis and treatment of destructive behavior, respectively (but they remain Category III).

Q: Do all payers have to adopt the 2019 CPT codes?

Yes. Under HIPAA, if a payer accepts electronic claims submissions, they must utilize Category I CPT codes.

Q: Are all payers required to implement the new CPT codes as of January 1, 2019 or by some other deadline?

No. Payers have their own procedures and timelines for implementing new codes, so providers must obtain that information from each payer with whom they work.

Q:  What is a Qualified Healthcare Professional (QHP)?

In 2013, the American Medical Association (AMA) established a definition for a qualified healthcare professional (QHP), in terms of which providers may report medical services: “A ‘physician or other qualified health care professional’ is 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.”

Possible QHPs for the 2019 CPT codes for adaptive behavior services, depending on state licensure laws, health insurance regulations, Centers for Medicare & Medicaid Services’ (CMS) and/or other payers’ policies:

    • Licensed Behavior Analysts
    • Board Certified Behavior Analysts, Board Certified Behavior Analysts-Doctoral
    • Other licensed professionals who have behavior analysis in their profession’s scope of practice and their individual scope of competence

Q:  How does the CPT time rule for face-to-face time work for 15-minute codes?

With time based codes a CPT code may be reported when half the time increment outlined in the code descriptor has been met.  In the case of the 2019 Adaptive Behavior codes, work lasting 8-22 minutes is reportable as one unit; work lasting less than 8 minutes is not reportable.

Q:  What should I be doing to prepare?

  • Alert your payers about the new codes!
  • Use the code-conversion table and other resources from our website to work with payers to achieve consistent use of the 2019 code set.
  • If you haven’t already, give payers the BACB’s ASD treatment guidelines and APBA’s white paper on identifying ABA interventions.
  • Obtain accurate MUEs for the new codes.
  • Review your contracts.
  • Calculate the value of your services. Have meaningful data on the full cost of providing a service (e.g., cost of staff compensation packages including benefits, liability insurance, malpractice insurance, practice expenses such as equipment, reinforcers, technology, data collection software, EMRs) to discuss with payers.
  • Negotiate! As a party to your contract you always have the ability to request a review of contract terms with you payers. This includes reevaluation of reimbursement rates and payer policies and procedures related to your agreement. Be sure that any requests for renegotiation comply with your contract terms regarding submission format and notice criteria/timelines.

Q: Are there established values (relative value units) for the new CPT codes in 2019?

No. The new codes will be carrier priced for 2019. That means that payers will establish reimbursement rates for each code with providers via the contract negotiation process.

Q: What are the conditions under which 97155 can be billed concurrently with codes for direct treatment of the patient?

See the table below.

Concurrent Billing Overview

Q: How is time for the QHP’s day-to-day review of data and treatment planning captured?

There is no separate code for those indirect services in the new CPT code set (nor was there in the Category III CPT code set). Some payers may supplement the adaptive behavior services code set with a HCPCS or other CPT code (e.g., H0032, G9012, H2019) to report indirect activities. In the event payers do not, the activities that occur prior to and after the face-to-face time should be bundled so that reimbursement for those codes captures both face-to-face and non-face-to-face time.

Q: Can I report 97155 for treatment planning conducted by the QHP while the technician implements treatment with the patient?

No. Code 97155 should be reported only for services where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient.

Q: Can I bill for supervision of technicians without the patient present?

No. That is an indirect service for which CPT does not allow stand-alone codes. Some payers may allow the use of HCPCS or other CPT codes to report that work.

Q: Do payers allow use of the codes to report telehealth delivery of ABA assessment or treatment services?

This varies based on state law and payer policy. Review your contracts and provider manuals for guidance on whether telehealth is approved by your individual payers.

Q: My payers currently pay for treatment planning under a HCPCS code. Am I now limited to only the 2019 CPT codes?

No. Payers may supplement the 2019 CPT codes with HCPCS or other CPT codes for indirect services or other activities, which would be specified in your modified 2019 contracts.

Q: Why do I need resources on the 2019 CPT code set other than code descriptors I’ve seen on some slides or the code conversion table that was distributed by the Steering Committee?

The 2019 CPT® Code Book and the CPT® Assistant article both contain information that is essential for a full understanding of the code set and how it should be reported. Those materials are copyrighted by the AMA, so we cannot distribute them without express permission from the AMA.

Q: What is “direction” as that term is used in code 97155 and how does it differ from “supervision”?

“Direction” in the context of code 97155 refers to the QHP directly monitoring the delivery of treatment to a patient by a behavior technician. The focus is on ensuring that treatment protocols are implemented correctly in order to maximize benefit to that patient. Direction of a technician includes, but is not limited to, the QHP frequently observing the technician implementing the patient’s protocols with the patient, providing instructions and confirming or corrective feedback as needed, and/or demonstrating correct implementation of a new or modified treatment protocol with the patient while the technician observes, followed by the technician implementing the protocol with the patient while the QHP observes and provides feedback. That service should be reported and billed using code 97155 (adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional). The technician’s time is separately reportable under 97153 (adaptive behavior treatment by protocol administered by technician under the direction of a physician or other qualified health care professional). Time reported and billed must be face-to-face time with the patient.

“Supervision” of a technician or other employee by a QHP generally refers to processes through which the QHP ensures that the supervisee (a) practices in a competent, professional, and ethical manner in accordance with the standards of the profession; (b) engages with and follows the employer’s policies and procedures; (c) continues to develop their knowledge and skills; and (d) receives the personal support needed to cope with the stressors and demands of their position. “Supervision” may also involve activities to enable the supervisor and supervisee to comply with specific requirements for obtaining or maintaining a paraprofessional or professional credential, such as a certification or license, or to fulfill ethical responsibilities. Supervision activities that do not involve delivery of services directly to patients are generally not reportable or billable to health plans using CPT codes, though some payers may allow them to be billed using HCPCS or other codes. Those that do involve direct delivery of services to maximize benefits to individual patients may be reportable and billable to a health plan and fulfill some supervision requirements for certification or licensure purposes, but only the former should be reported to the health plan.

Note: The Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.) use the terms “case supervision” and “clinical direction” to refer to the work conducted by the QHP to develop, deliver, and oversee implementation of a patient’s treatment plan. Those terms encompass both direct contact with the patient or caregivers and indirect services. Direct adaptive behavior services by the QHP include delivering assessment or treatment face-to-face with the patient (reported with codes 97151, 97153 with modifier, 97155, 0362T, 0373T, 97158) or caregiver(s) (reported with codes 97156, 97157). Only code 97151 allows non-face-to-face activities (reviewing records, scoring assessments, and preparing a treatment plan or progress report) to also be reported and billed. Indirect services by the QHP include activities involved in ongoing monitoring of patient progress and revising protocols, preparing for assessment or treatment sessions by the QHP and/or technicians, reviewing data, and writing progress notes – that is, activities like those described in the “prior” and “after” sections of the clinical examples in this document. As indicated in the introduction, there is no stand-alone CPT code for those indirect services, so they must be bundled with direct services for payment unless the payer allows them to be reported and billed with a HCPCS or other code.

CODE-SPECIFIC QUESTIONS

97151

Q: Is 97151 intended to be used for day-to-day assessment and treatment planning?

No. This code is intended for reporting initial assessment and treatment plan development and reassessment and progress reporting by the QHP (timeframes for reassessments are determined by payer policy or medical necessity). 97151 includes face-to-face time with the patient and/or caregivers to conduct assessments as well as non-face-to-face time for reviewing records, scoring and interpreting assessments, and writing the treatment plan or progress report. The QHP must have conducted both the face-to-face and non-face-to-face activities to report this service. Day-to-day assessment and treatment planning by the QHP are bundled into the treatment codes below (i.e., 97153-97158 and 0373T); therefore, 97151 cannot be used to report those indirect services because they do not meet all requirements of the code descriptor.

Q: Why does 97151 include non-face-to-face work and the other codes in the 2019 set do not?

Assessments and reassessments require extensive non-face-to-face time for the QHP to score assessments, review records and data, and write or update the treatment plan. That can take several hours, and in many cases occurs across multiple dates of service. That is why only this code allows for reporting of non-face-to-face time.

97152

Q: Does the descriptor for 97152 indicate that technicians can perform assessments independently?

No. This code is for reporting supplemental assessments conducted by the technician that the QHP determines are needed to develop the treatment plan or progress report (see code 97151). Additionally, as indicated in the clinical example, the QHP reviews the assessment procedures with the technician and has the technician practice recording data. That may occur on the day of an assessment session with a patient or several days leading up to the session(s). That work by the QHP is bundled into the value of code 97152 and is not reported separately.

0362T

Q: What is meant by “on site”?

On site is defined as the QHP being “immediately available and interruptible.” This means that the QHP is at the same site and can join the session if needed.

Q: Can 0362T be reported when additional technicians are needed for safety, but on an impromptu basis (e.g., if a destructive behavior occurs unexpectedly and a second or third technician steps in to help)?

No. These services should be preauthorized for cases where all four of the criteria in the code descriptor are met.

Q: What is meant by a “customized environment”?

For codes 0362T and 0373T, the term “customized” means that the environment is configured to safely conduct a functional analysis of destructive behavior (0362T) or treatment for that behavior (0373T). For some patients, this can be accomplished in the home. For example, in the case of a patient who displays aggression using objects, those objects that the patient might use as dangerous weapons (e.g., a wooden baseball bat) would be removed and replaced with soft items (e.g., a foam baseball bat). Other patients may require treatment in a padded treatment room. For example, a patient with severe head banging may require functional analysis and initial treatment in a padded treatment room because the behavior causes tissue damage and places the patient at risk for detached retinas.

97153

Q: How do I report a typical direct treatment session that is rendered by a QHP?

If no protocols have been modified and a QHP is simply acting in place of the technician, report 97153 with a modifier to indicate the higher-level service provider.

Q: Can I report 97153 and 97155 concurrently?

Yes, as long as the criteria in the descriptors of both codes are met. A single QHP may not report 97153 and 97155 concurrently. See the Concurrent Billing Overview table in the Other Frequently Asked Questions section.

97154

Q: Can I report 97154 and 97158 concurrently?

No. 97158 is intended to be reported for QHP-led group sessions only.

Q: Can I report 97154 and 97155 concurrently?

Yes, as long as the criteria in the descriptors for both codes are met. A single QHP may not report 97154 and 97155 concurrently.

Q: What constitutes a “group”?

A group includes at least 2 patients but no more than 8.

Q: Do I report a group code (either 97154 or 97158) for each patient in the group session?

Yes. Report the applicable code for each patient attending the group session. 

97155

Q: When do I report 97155?

In two cases: (1) When a QHP conducts 1:1 direct treatment with the patient to observe changes in behavior or troubleshoot treatment protocols; or (2) when the QHP joins the patient and the technician during a treatment session to direct the technician in implementing a new or modified treatment protocol. In the second case, 97153 should be reported concurrently (see Concurrent Billing Overview in the Other Frequently Asked Questions section).

Q: What is an adaptive-behavior service protocol?

An adaptive behavior service protocol encompasses (a) a written description of procedures for implementing a specified service to address a patient’s assessment or treatment goal(s) and (b) implementation of the procedures with the patient.

Q: What is adaptive-behavior service protocol modification?

Adaptive behavior service protocol modification involves changes made by a qualified health care provider (QHP) to the procedures for implementing an adaptive behavior service. Protocol modification includes but is not limited to (a) adjustments to specific components of a protocol (e.g., treatment targets, treatment goals, observation and measurement, reinforcers, reinforcer delivery, prompts, instructions, materials, discriminative stimuli, contextual variables); (b) observations to determine if the protocol components are functioning effectively for the patient or require adjustments; (c) active direction of a technician while the technician delivers a service to a patient to ensure that the procedures are being implemented correctly, to correct errors in implementation, or to train the technician to implement a modified protocol; and (d) QHP implementation of the protocol with the patient to determine if changes are needed to improve patient progress or to test a modified protocol. Any protocol-modification services that are delivered during face-to-face sessions with patients or caregivers are billable. Modifying written protocols is an indirect service that is not reported separately, but is bundled with 97155 for payment.

97156

Q: Can I report 97156 for services delivered to parents while the patient is receiving direct treatment elsewhere (e.g., when the patient is in a treatment session with a technician and the parents are meeting with the QHP in another room for a family training)?

Yes. Those are separate and distinct services delivered to different family members by different providers.

Q: Who constitutes a “caregiver”?

This is determined by payer policy. Immediate family members are almost always covered, but some payers may have a broader definition and include others such as babysitters, teachers, day care providers, etc.

97157

Q: Do I report 97157 for every attendee in the group session?

No. Report this code for each set of caregivers for a given patient who attend the group session. For example, if five sets of parents attend the group session, report the code once for each set.

97158

Q: Can I report 97154 and 97158 concurrently?

No. 97158 is intended to be reported for QHP-led group sessions only.

Q: What constitutes a “group”?

A group includes at least 2 patients but no more than 8.

Q: Do I report 97158 for each patient in the group session?

Yes. Report this code for each patient attending the group session.

Q: What is an adaptive-behavior service protocol?

An adaptive behavior service protocol encompasses (a) a written description of procedures for implementing a specified service to address a patient’s assessment or treatment goal(s) and (b) implementation of the procedures with the patient.

Q: What is adaptive-behavior service protocol modification?

Adaptive behavior service protocol modification involves changes made by a qualified health care provider (QHP) to the procedures for implementing an adaptive behavior service. Protocol modification includes but is not limited to (a) adjustments to specific components of a protocol (e.g., treatment targets, treatment goals, observation and measurement, reinforcers, reinforcer delivery, prompts, instructions, materials, discriminative stimuli, contextual variables); (b) observations to determine if the protocol components are functioning effectively for the patient or require adjustments; (c) active direction of a technician while the technician delivers a service to a patient to ensure that the procedures are being implemented correctly, to correct errors in implementation, or to train the technician to implement a modified protocol; and (d) QHP implementation of the protocol with the patient to determine if changes are needed to improve patient progress or to test a modified protocol. Any protocol-modification services that are delivered during face-to-face sessions with patients or caregivers are billable. Modifying written protocols is an indirect service that is not reported separately, but is bundled with 97158 for payment.

0373T

Q: For 0373T, do I report each technician’s time separately?

No. Report only the total time of one technician. Example: if three technicians are needed for a 3-hour session, report 12 units of 0373T (15 minutes x 12 units = 180 minutes, or 3 hours).

Q: For 0373T, what is meant by “on site”?

On site is defined as the QHP being “immediately available and interruptible.” This means that the QHP is at the same site and can join the session if needed.

Q: Can 0373T be billed concurrently with 97155 if the QHP directs the technician during the session?

No. That and other indirect services must be bundled with this code.

Q: For 0373T, do I report each technician’s time separately?

No. Report only the total time of one technician. Example: if three technicians are needed for a 3-hour session, report 12 units of 0373T (15 minutes x 12 units = 180 minutes or 3 hours).

Q: What is meant by a “customized environment”?

For codes 0362T and 0373T, the term “customized” means that the environment is configured to safely conduct a functional analysis of destructive behavior (0362T) or treatment for that behavior (0373T). For some patients, this can be accomplished in the home. For example, in the case of a patient who displays aggression using objects, those objects that the patient might use as dangerous weapons (e.g., a wooden baseball bat) would be removed and replaced with soft items (e.g., a foam baseball bat). Other patients may require treatment in a padded treatment room. For example, a patient with severe head banging may require functional analysis and initial treatment in a padded treatment room because the behavior causes tissue damage and places the patient at risk for detached retinas.

Q: What is an adaptive-behavior service protocol?

An adaptive behavior service protocol encompasses (a) a written description of procedures for implementing a specified service to address a patient’s assessment or treatment goal(s) and (b) implementation of the procedures with the patient.

Q: What is adaptive-behavior service protocol modification?

Adaptive behavior service protocol modification involves changes made by a qualified health care provider (QHP) to the procedures for implementing an adaptive behavior service. Protocol modification includes but is not limited to (a) adjustments to specific components of a protocol (e.g., treatment targets, treatment goals, observation and measurement, reinforcers, reinforcer delivery, prompts, instructions, materials, discriminative stimuli, contextual variables); (b) observations to determine if the protocol components are functioning effectively for the patient or require adjustments; (c) active direction of a technician while the technician delivers a service to a patient to ensure that the procedures are being implemented correctly, to correct errors in implementation, or to train the technician to implement a modified protocol; and (d) QHP implementation of the protocol with the patient to determine if changes are needed to improve patient progress or to test a modified protocol. Any protocol-modification services that are delivered during face-to-face sessions with patients or caregivers are billable. Modifying written protocols is an indirect service that is not reported separately, but is bundled with 0373T for payment.