Supplemental Guidance Resource

January 14, 2019

The Steering Committee for the ABA Services Workgroup has prepared the article, Supplemental Guidance on Interpreting and Applying the 2019 CPT Codes for Adaptive Behavior Services, to assist providers, billers, and payers in using the Category I and modified Category III CPT® codes for adaptive behavior services that went into effect January 1, 2019. That document is meant to supplement the information about the new codes that is published in the 2019 CPT® Code book (available from the American Medical Association [AMA] Store) and an article in the November 2018 issue of the AMA’s CPT® Assistant newsletter (to purchase, call 1-800-621-8335, select option 2 in the recorded menu, and ask for item BI506118). If you do not yet have both of those documents, it is essential that you obtain them and review the Supplemental Guidance article as soon as possible.

The Steering Committee has also communicated with a number of payers about their implementation of the new codes. The content of some of the most common communications is reflected in the Q&As in the Supplemental Guidance article. That includes clarifications regarding (a) the use of a modifier with code 97153 when direct treatment is rendered by the QHP instead of a technician; (b) activities included in “protocol modification” for codes 97155, 97158, and 0373T; and (c) the relationship between “direction of technician” as it is used in code 97155 and some common usages of the term “supervision.

The Supplemental Guidance article also addresses concurrent billing of code 97155 (adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician) and code 97153 (adaptive behavior treatment by protocol, administered by a technician under the direction of a QHP). We have provided the following additional clarifications about that issue to some payers:

Frequent direction of technicians implementing treatment protocols with patients by the professional behavior analyst is essential for the ethical and effective delivery of ABA services. That service is separate and distinct from the service delivered to a patient by a technician under code 97153. The AMA CPT® Editorial Panel recognized that in approving a distinct Category I CPT® code for each of those services. As indicated in the CPT® Assistant article,

Adaptive behavior treatment by protocol (97153) is administered by a technician under the direction of a physician/other QHP, who may provide direction during the actual treatment, which represents face-to-face skill training delivered to a patient. The physician/other QHP designs the treatment protocols, assists the technician in adhering to the protocols, and analyzes the technician-recorded data to determine whether the protocol is producing adequate patient progress (97155).

Adaptive behavior treatment with protocol modification (97155) is administered by a physician/other QHP face-to-face with a single patient to resolve one or more problems with the protocol. They may simultaneously direct a technician in administering the modified protocol while the patient is present. Direction to the technician is not reported separately. – CPT® Assistant, November 2018/Volume 28 Issue 11, p. 6. Chicago: American Medical Association.

The AMA has clearly indicated that the services represented by codes 97155 and 97153 may be reported concurrently. That is evidenced by the references to simultaneous direction of a technician in the descriptor for code 97155 and the text cited above, the lack of any exclusionary parentheticals in the CPT® 2019 code book that prevent the two services from being reported concurrently, and the following coding tip in the CPT® Assistant article:

Do not report code 97155 in conjunction with codes 90785-90899, 96105-96155, 92507, 97532, or G0515. Note that when the physician/other QHP directs the technician about the treatment protocol without the patient present, the service is considered as bundled with the above service codes and, therefore, it should not be reported separately. Code 97155 may be reported in two scenarios: when the physician/other QHP is delivering the treatment with the client one-to-one or when the physician/other QHP is directing the technician in delivering treatment (code 97153) and both the technician and the client are present. – CPT® Assistant, November 2018/Volume 28 Issue 11, p. 5. Chicago: American Medical Association.

In short, when a QHP directs a technician under code 97155, concurrent billing of code 97153 is consistent with the profession’s standards of care, our Steering Committee’s intended use of those codes, and AMA guidance. It does not constitute duplicate billing because the two codes represent two different services.

We encourage providers to share the Supplemental Guidance article and this letter with their payers and billers. Additionally, although we understand the challenges presented to providers and payers alike whenever billing codes change, we encourage all parties to be patient and engage in respectful dialogue toward ensuring that the process of implementing the 2019 CPT® codes for adaptive behavior services is as smooth as possible.