CPT 97151, 97152, 97153, 97158, 0373T – Applied Behavior Analysis (ABA)

Feb 28, 2022 | Medical billing basics

INTRODUCTION – Applied Behavior Analysis (ABA)

Applied Behavior Analysis (ABA) is the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significa improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior. ABA is a behavior intervention model based on reliable evidence-based practices focusing on targeted skills in all areas of development. The Division of Health Care Financing and Policy (DHCFP) utilizes the Center for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and Behavior Analyst Certification Board (BACB) “Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.)” as guiding principles for this policy.

CPT CODE AND Descripton

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.

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.

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.

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.

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.

0373T Adaptive behavior treatment with protocol modification (exposure treatment)

  • Use for one-on-one direct ABA services with patient who exhibits destructive behavior–Destructive behaviors are defined as: Maladaptive behaviors associated with a high risk of medical consequences or property damage Examples include (but are not limited to):}Self-injury requiring medical attention }Aggression with injury to others}Breaking furniture, walls or windows}
  • Conducted in an environment that is customized to the patient’s behavior
  • Two or more technicians with a physician or other QHP on site}

Per AMA — On-site is defined as immediately available and interruptible to provide assistance and direction throughout the performance of the procedure. However, the physician or other qualified health care professional does not need to be present in the room when the procedure is performed.}If the physician or QHP personally performs these one-on-one direct services with patient, this code would be used

Medically Unlikely Edits (MUEs)

For information on MUE’s, please refer to the CMS website for the latest update: https://www.cms.gov/medicare/coding/nationalcorrectcodinited/mue.html

PRIOR AUTHORIZATION REQUIREMENTS

  1. Behavioral screens do not require prior authorization.
  2. Behavioral initial assessment and re-assessments do not require prior authorization. Assessments are limited to one in every 180 days or unless prior authorized.
  3. Adaptive Behavioral Treatment (individual and group) requires prior authorization from
    the Quality Improvement Organization (QIO)-like vendor.
  4. Adaptive Family Behavioral training (individual and group) requires prior authorization from the QIO-like vendor.
  5. ABA services identified through an IEP. When an IEP is issued by the school system, the IEP must accompany a request for ABA services and coordination of services is expected.
  6. Each authorization is for an independent period of time as indicated by the start and end date of the service period. If a provider believes it is medically necessary for services to be rendered beyond the scope (units, time period or both) of the current authorization, the provider is responsible for the submittal of a new prior authorization request.

NON-COVERED SERVICES

  1. Services which do not meet Nevada Medicaid medical necessity requirements.
  2. Services used to reimburse a parent/guardian for participation in the treatment plan.
  3. Services rendered by the parent/guardian.
  4. Services that are duplicative services under an IFSP or an IEP.
  5. Treatment whose purpose is vocationally or recreationally based.
  6. Services, supplies or procedures performed in a non-conventional setting including but not
    limited to Resorts, Spas and Camps.
  7. Custodial services:
    a. For the purpose of these provisions, custodial care:
  8. Shall be defined as care that is provided primarily to assist in the activities of daily living (ADLs) such as bathing, dressing, eating, and maintaining personal hygiene and safety;
  9. Is provided primarily for maintaining the recipient’s or anyone else’s safety;
    and
  10. Could be provided by persons without professional skills or training.
  11. Services not authorized by the QIO-like vendor if an authorization is required according to policy.
  12. Respite services.
  13. Child care services.
  14. Services for education.
  15. Equine therapy.
  16. Hippotherapy.
  17. Phone consultation services.
  18. Care coordination and treatment planning billed independently of direct service.
  19. ABA services cannot be reimbursed on the same day as Basic Skills Training (BST) Psychosocial Rehabilitation (PSR) as defined in MSM Chapter 400.

PARENT/GUARDIAN RESPONSIBILITY

A. The parent/guardian when applicable must:

  1. Be present during all provider training and supervisory visits that occur during
    home-based services. A parent/guardian may designate an authorized
    representative, who is 18 years of age or older, to participate in the
    parent/guardian’s absence during home-based services.
  2. Participate in discussions during supervisory visits and training.
  3. Participate in training by demonstrating taught skills to support generalization of
    skills to the home and community environment.
  4. Sign the treatment plan indicating an understanding and agreement of the plan.
  5. Participate in treatment hours.
  6. Keep scheduled appointments.
  7. Inform provider within 24 hours if the appointment needs to be rescheduled.

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