Adaptive behavior services address deficient adaptive behaviors or maladaptive behaviors that require assessment and treatment under the guidance of a Qualified Health-Care Professional (QHCP) working with therapists and technicians. The provider billed these services against the patient depending on the code of treatment that the patient receives and is payable by the payer aka insurance company if the claim is correct and compliant with the policy.
The CPT® codes below have been approved by the American Medical Association (AMA) for applied behavior analysis assessment and treatment – described as “adaptive behavior services”. These services can be further classified into two major parts with two grades Categories I (FDA approved) & Categories III respectively with different CPT
- Adaptive behavior Assessment
- Adaptive behavior Treatment
New Category I (permanent) and revised Category III (temporary) CPT® codes for adaptive behavior services went into effect on January 1, 2019. The use of Category I and revised Category III CPT® Codes to report adaptive behavior services is mandatory under HIPAA. Also Category I has a higher acceptance rate with the payer for its uniformity and consistency. All procedure have been given a universal increment time of 15 min with no Add on Codes but modifiers and all the Social skills code has been replaced with group treatment codes
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Understanding Codes:
While 97151 & 97152 are CPT Category I for Adaptive behavior Assessment deals with QHCP dealing with patient or parent/guardian with an allocated 15 min face to face assessment to determine the treatment. However, 97151 can be done with records and in presence of his guardian alone
Similarly, 0362T needs to be administered by a QHP for 15 min with the assistance of two or more technicians; this is usually done when the patient has aggressive tendencies and can cause harm to himself and others.
CPT Category I for Adaptive behavior Treatment may vary from CPT 97153 to 97158.
So what does this CPT Category I in the Treatment spectrum of code stand for?
97153. being the golden protocol administered by QHP/technician with a 1 on 1 patient approach for 15 minutes face-to-face. While 97154. is a group adaptive behavior protocol that can invoke two or more (max 8) patients being handled by a technician or under the guidance of QHP for 15 minutes
However, 97155. is AB protocol modification treatment requiring a QHP/technician with the 1 on 1 patient for 15 minutes sessions. While 97156. Is a Family adaptive behavior treatment guidance, administered by physician or QHP with or without patient for 15 mins. 97157. Involves multiple-family group adaptive behavior treatment guidance, administered by a physician or other QHP(without the patient present), face-to-face with multiple sets (2 – 8 pax) of guardians/caregivers, every 15 minutes.
Kindly Note any procedure done by the technician under the supervision of QHCP cannot be labeled as direct such as 97151, 97153 with a modifier, 97155, 0362T, 0373T, 97158.
While 97158. Focuses on Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional face-to-face with multiple patients, every 15 minutes.
Similarly 0373T. Treatment has adaptive behavior with protocol modification needs to be administered by a QHP for 15 min with the assistance of two or more technicians; this is usually done when the patient has aggressive tendencies and can cause harm to himself and others.
CLAIM & DIVERSITY :
Any insurance claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. ICD-10 Codes are primarily used for insurance purposes. They also provide valuable data when it comes to improving healthcare for patients because they allow clinicians to form a better understanding of various complex diseases
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| ICD-10 Code | ICD-10 Descriptor | DSM-5 Code | DSM-5 Descriptor |
| F84.0-F84.9 | Pervasive developmental disorders | 299.0 | Autism spectrum disorder |
F84.0: Autistic Spectrum Disorder
This code is applicable to infantile autism, autism spectrum disorder, Kanner’s syndrome, and infantile psychosis.
F84.2: Rett’s Syndrome
Rett’s syndrome is extremely rare, and it occurs almost exclusively in girls. The most common symptom is constant and repetitive hand movements. In some cases, it also affects their capacity to breathe.
F84.3: Other Childhood Disintegrative Disorders
This code can apply to several conditions, including dementia, disintegrative psychosis, symbiotic psychosis, and Heller’s Syndrome. It is only suitable for individuals who are 0 to 17 years of age.
F84.5: Asperger’s Syndrome
The F84.5 code applies to Asperger’s syndrome only. This neurodevelopmental condition causes a person to experience extreme challenges when engaging in nonverbal communication and social activities. Individuals with this disorder often behave in a very repetitive manner.
F84.9: Pervasive Developmental Disorder (Unspecified)
This ICD-10 code can be used to specify conditions such as active but odd autism, a pervasive developmental disorder of a residual state, autism spectrum disorder, and savant syndrome.
NOTE: Claims submitted without ICD-10-CM codes will be returned & DENIED.
Tele-Health Model:-
During the due course of the pandemic COVID-19, many Applied Behavior Analysis (ABA) businesses quickly pivoted to a telehealth model to serve clients and prevent interruption to care. But now, with stay-at-home orders lifted, clinicians are seeing patients in person – with treatment looking far different than it did before March 2020. However, each payer has to be updated, informed & checked whether they acknowledge the Telehealth model.
One of the codes, CPT code 99072, relates to the additional supplies and clinical staff time required to perform safety protocols for the provision of evaluation, treatment, or procedural services during a public health emergency in a setting where extra precautions are taken.
This includes patient symptom checks over the phone and upon arrival, donning and removing personal protective equipment (PPE), and increased sanitation measures to prevent the spread of communicable disease, as well as supplies and materials clinicians use to care for patients — all of which were formerly an out-of-pocket expense for practices. Any remote supervision does require the inclusion of the GT modifier.
According to the AMA, CPT code 99072 should be reported only once per in-person visit, per provider identification number (PIN), regardless of the number of services performed during the visit. The AMA also noted that it has submitted recommendations to the Centers for Medicare & Medicaid Services (CMS) to “inform payment” of the new CPT code.
While billing or claiming a service the qualified healthcare professional must use code under the HIPAA Taxonomy.
Claims also require HIPAA taxonomy designation for each type of provider, as approved designations are given below:
- Master’s level and above for behavior analyst – 103K00000X
- Assistant behavior analyst – 106E00000X
- Behavior technician – 106S00000X
Rates for reimbursement are based on individual analyses by commercial and centers for Medicare and Medicaid Services ABA rates. These can vary depending on location.
Rates also depend on the terms of your network agreement as a network provider.
Claims Management
One of the most integral components of your claims process is coding each claim accurately with the correct ABA billing code. Doing so will offer you your best chance at an approved claim. This is one of the biggest challenges for providers offering ABA therapy. ABA billing codes are complex, specific, and require great understanding. With clients to focus on, it can be difficult to be a billing expert as well.
Denial Management
Even when ABA billing codes are accurate, denials still happen. One of the biggest challenges that ABA therapy providers face is their denial management process. Revenue is lost when a denial is not caught, corrected, and submitted within the required time frame.
We @ AMROMED LLC understand the difficulties and burden as a healthcare professional, to spend your important time selecting the correct codes so that everything will go as smoothly as possible. Unfortunately, it’s nearly impossible to memorize around seventy-thousand. You’ll have to look them up to ensure accuracy. Hence, many providers do not realize that they do not have to try and become ABA billing experts on their own. In fact, providers with the highest-functioning billing processes outsource claim and denial management to qualified practice management or revenue cycle management billing partner.
We @ AMROMED LLC have a 12-year of industry experience with a team comprising of 200+ employees providing 24 hours of instant backend support while working at various timelines using advanced technology creating a smooth end-to-end encrypted billing software solution that guarantees a smooth hassle-free revenue-generating cycle management. Interested in having us manage your ABA Medical billing for you? Want to know more and see growth click right here.
