HealthCare News

ABA Code Changes: Effective for services on or after January 1, 2019

Issue: #406 JAN2019

Topic: Coding/Billing


The American Medical Association released eight new CPT® Category I codes (96151, 96152, 96153, 96154, 96155, 96156, 96157, 96158) and revised two CPT® Category III codes (0362T, 0373T) for billing applied behavior analysis (ABA) services. These new codes will replace the CPT® Category III codes that have been used for ABA services and the new codes should be used for services on or after January 1, 2019.

The following CPT® Category III codes for ABA will be deleted December 31, 2018: 0359T, 0360T, 0361T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T and 0372T. The CPT® Category III codes include primary codes for the first 30 or 60 minutes with add-on codes for additional time for the assessment and treatments. The CPT® Category I codes are “per 15 minutes” time-based codes and add-on codes have been eliminated.

Here are some important tips to remember when submitting ABA claims:

  • For services rendered prior to January 1, 2019, use CPT® Category III codes.
  • For services rendered on or after January 1, 2019 use CPT® Category I codes or the two revised CPT® Category III codes.
  • Already authorized services do not need a new precertification however coding should reflect the appropriate codes in place at the time the services were rendered.
  • Documentation must support all requirements for each code submitted on a claim. For example, time based codes must include documentation that supports the number of minutes spent face-to-face with the provider unless otherwise specified in the AMA 2019 CPT® Professional book.
  • Documentation that does not support a submitted code will result in that claim line being denied.
  • The request form will be available on the Blue Cross Blue Shield of North Dakota (BCBSND) provider page under Forms and Documents (https://www.bcbsnd.com/web/providers/forms), “ABA services for Autism Spectrum Disorder Request Form”.

Coding Tips and Guidelines from the AMA 2019 CPT® Professional book.

  • CPT® codes 97151-97152 describe behavior assessments and are differentiated by the test administrator
  • CPT® codes 97153-97158 describe adaptive behavior treatment. The codes are differentiated by the performing provider, and individual, group or family.
  • If the physician or other qualified healthcare professional (QHP) personally performs the technician activities, his or her time engaged in these activities should be included as part of the required technician time to meet the component of the code. Only count the time of one technician when two or more are present.
  • Codes 97152, 0362T may be reported separately with 97151 based on the time that the patient is face-to-face with one or more technician(s).
  • Do not report codes 97154, 97157 or 97158 if the group has more than 8 patients.
  • For assistance with code selection of 97152 and 0362T, see the Guide to Selection of Codes 97152 and 0362T on page 711 in the AMA 2019 CPT® Professional book.
  • For assistance with code selection of 97153, 97155, 0373T, see Guide to Selection of Codes 97153, 97155, 0373T on page 712 in the AMA 2019 CPT® Professional book.
  • 0362T or 373T are reported based on a single technician’s face-to face-time with the patient and not the combined time of multiple technicians (e.g., one hour with three technicians equals one hour of service).
  • CPT® code 0362T is revised from exposure behavioral follow-up assessment to behavior identification supporting assessment. 0363T has been deleted.
  • CPT® code 0373T is revised from exposure adaptive behavior treatment with protocol modification requiring two or more technicians for several maladaptive behavior(s) to adaptive behavior treatment with protocol modification. 0374T has been deleted.
  • CPT® code 0373T is revised from exposure adaptive behavior treatment with protocol modification requiring two or more technicians for several maladaptive behavior(s) to adaptive behavior treatment with protocol modification. 0374T has been deleted.
  • Identification supporting assessment (0362T) and adaptive behavior treatment with protocol modification (0373T) include the following required components:
    • Administration by the physician or other qualified health care professional who is on-site but not necessarily face-to-face with the patient;
    • “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.
    • With the assistance of two or more technicians;
    • For a patient with destructive behavior that requires the presence of a team;
    • Completion in an environment that is customized to the patient’s behavior.

The below table represents the coding conversion.

Assessment Codes; Development of Individualized Treatment Plan
Services rendered through December 31, 2018, utilize CPT codes below Units Conversion Services rendered January 1, 2019, and after, utilize CPT codes below Unit
Assessment Codes 0359T: Behavior identification assessment by the physician or other qualified healthcare professional, face-to-face with patient and caregiver(s). Includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report. Per Services 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, non-face-to-face analysis past data, scoring/interpreting the assessment, and preparing the report/treatment plan. Per 15 minutes
Assessment Codes 0360T: Observational behavioral follow-up assessment. Include physician or other qualified healthcare professional direction with interpretation and report, administered by one technical: first 30 minutes of technician time, face-to-face with the patient. First 30 minutes

97152: Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with patient, each 15 minutes. Per 15 Minutes
Assessment Codes 0361T: Observational behavioral follow-up assessment, each additional 30 minutes of technician time, face-to -face with the patient Each additional 30 minutes
Assessment Codes 0362T: Exposure behavioral follow-up assessment. Includes physician or other qualified healthcare professional direction with interpretation and report administered by physician or other qualified healthcare professional with the assistance of one or more technicians; first 30 minutes of technician(s)time, face-to-face with the patient. First 30 minutes

0362T: Behavioral identification supporting assessment, each 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.
Per 15 Minutes
Assessment Codes 0363T: Exposure behavioral follow-up assessment, each additional 30 minutes of technician(s) time, face-to-face with the patient (list separately in addition to code for primary procedure). Each additional 30 minutes
Treatment Codes: Implementation and Management of Treatment Plan
Services rendered through December 31, 2018, utilize CPT codes below Units Conversion Services rendered January 1, 2019, and after, utilize CPT codes below Unit
Treatment Codes 0364T: Adaptive behavior treatment by protocol administered by technician, face-to-face with one patient; first 30 minutes of technician time. First 30 minutes 97153: Adaptive behavior treatments by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes. Per 15 minutes
Treatment Codes 365T: Adaptive behavior treatment by protocol, each additional 30 minutes of technician time (list separately in addition to code for primary procedure) Each additional 30 minutes
Treatment Codes 373T: Exposure adaptive behavior treatment with protocol, modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technician’s time, face-to-face with patient. First 30 minutes 0373T: Adaptive behavior treatment with protocol modification, each 15 minutes of technician’s 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.

Per 15 Minutes
Treatment Codes 0374T: Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technician’s time face-to-face with patient. (list separately in addition to code for primary procedure) Each additional 30 minutes
Treatment Codes 0368T: Adaptive behavior treatment with protocol modification administered by physician or other qualified healthcare professional with one patient; first 30 minutes of patient face-to-face time. First 30 minutes 97155: Adaptive behavior treatments with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. Per 15 Minutes
Treatment Codes 0369T: Adaptive behavior treatment with protocol modification administered by physician or other qualified healthcare professional with one patient; each additional 30 minutes of patient face-to-face time. (list separately in addition to code for primary procedure) Each additional 30 minutes
Treatment Codes 0366T: Group adaptive behavior treatment by protocol administered by technician, face-to-face with two or more patients; first 30 minutes of technician time. First 30 minutes 97154: Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. Per 15 Minutes
Treatment Codes 0367T: Group adaptive behavior treatment by protocol, each additional 30 minutes of technician time. Each additional 30 minutes
Treatment Codes 0372T: Adaptive behavior treatment social skills group, administered by physician or other qualified healthcare professional face-to-face with multiple patients. Untimed 97158: Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes. Per 15 Minutes
Treatment Codes
0370T: Family adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) Untimed 97156: Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes Per 15 Minutes
Treatment Codes 0371T: Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) Untimed 97157: Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes. Per 15 Minutes

References:

AMA 2019 CPT® Professional book.

Adaptive Behavior Assessment and Treatment Code Conversion Table – Available at https://www.bacb.com/wp-content/uploads/CPT_Codes_Crosswalk_.pdf