ABA CPT Codes – Updates for 2019

ABA Therapy Billing and coding has changed significantly over time. As many  of you know, for many years ABA therapy providers have been plagued and overwhelmed with inconsistent reimbursement and billing policies. If you have been affected by this, then this hits home.

Due to the inconsistency, the American Medical Association, or AMA,  CPT Editorial Panel released a set of temporary Category III codes in 2013. The temporary ABA Therapy Billing codes were significant, however, they were not a means to an end of a process. We all know, much like anything in our society, this process is an ever-changing system.

Differences: Category I & Category III Codes

For those who may not know, CPT codes are divided into two categories:

Category I

Permanent numerical codes that are five digits in length and can be used with CMS and any third party payer.

Category III

Temporary codes allowing the AMA to collect necessary data on emerging technology, services, and procedures. These codes are useful in figuring out how vast the services that are being submitted to the CPT Editorial Panel actually are.

Following the release of the temporary Category III codes in 2013, groups such as Autism Speaks and the BACB were created to be a net for feedback in order to effectively revise the code set. Fast forward to 2017, at the CPT Editorial Panel meeting, held in New Orleans, groups like the BACB and Autism Speaks were invited to share the feedback as well as their code changes proposal.. At the conclusion of this meeting, the panel approved eight Category I CPT codes and altered two Category III CPT codes. These codes went into effect at the beginning of this month, January 2019.

What’s the Change?

The new codes are replacing the temporary Category III codes that have been used ABA Therapy Billing for adaptive behavioral assessments and treatment services.

What Are the New Codes?

  • 97151: Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
  • 97152: Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes.
  • 97153: Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, every 15 minutes.
  • 97155: Adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, which may include simultaneous direction of a technician, face-to-face with one patient, every 15 minutes.
  • 97154: Group adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional,   with two or more patients, every 15 minutes.
  • 97158: Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, face-to-face with multiple patients, every 15 minutes.
  • 97156: Family adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), every 15 minutes.
  • 97157: Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, every 15 minutes.

The revised Category III codes are:

  • 0373T: Adaptive behavior treatment with protocol modification, every 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:
    • administered by the physician or other qualified healthcare professional who is on site;
    • with the assistance of two or more technicians;
    • for a patient who exhibits destructive behavior;
    • completed in an environment that is customized, to the patient’s behavior.
  •  0362T: Behavior identification supporting assessment, every 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:
    • administered by the physician or other qualified healthcare professional who is on site;
    • with the assistance of two or more technicians;
    • for a patient who exhibits destructive behavior;
    • completed in an environment that is customized to the patient’s behavior.

To see how the new Category I codes correlate to the old temporary Category III codes, check out these adaptive behaviors crosswalk created by BACB. These new code changes will directly affect ABA Therapy Billing and ABA providers, practices, and recipients as they are adopted by healthcare plans.

Check out how we can help you streamline your ABA Therapy Billing.