Autism Care Demonstration: Billing

Adaptive Behavior Services Current Procedural Terminology Codes

TRICARE-approved adaptive behavior services (ABS) Current Procedural Terminology (CPT^®) codes are specifically authorized and reimbursed under the Autism Care Demonstration (ACD) as approved by Health Net Federal Services, LLC (HNFS) during the clinical necessity review for the dates prescribed. ABS CPT codes are for use by applied behavior analysis (ABA) providers only. Please review TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.6.

SOLE/TIERED

Sole: Board Certified Behavior Analyst^® (BCBA^®) or Board Certified Behavior Analyst – Doctoral^® (BCBA-D^®) delivering direct 1:1 services.

Tiered: Assistant behavior analysts and behavior technicians (BTs) delivering direct 1:1 services.

Treatment plans must specify whether CPT 97153 will be delivered under the sole or tiered model, the location of services (e.g., home, clinic), and the recommended and requested total number of units for each CPT code listed.

Code Descriptions

T1023 Outcome Measures Submitted by BCBA/BCBA-D:

Used only by the BCBA/BCBA-D for submission of required data for outcome measures.
For outcome measures administered via telehealth, include modifier GT or 95 on the claim.
Transitions to 97151 for Pervasive Developmental Disorder Behavior Inventory (PDDBI) and outcome measures and from telehealth to indirect modality for authorizations issued after Aug. 1, 2021.
Authorizations approved prior to Aug. 1, 2021 with T1023 for outcome measures are permitted to run their course.
One unit per measure.

97151 Behavior Identification Assessment:

May be rendered by authorized ABA supervisors (or delegated to assistant behavior analyst).
Initial assessments:
- Prior to Aug. 1, 2021: Approved for 16 units per authorization period.
- On or after Aug. 1, 2021: Approved for 32 units per authorization period.
Reassessments approved for 24 units per authorization period.
Approved units includes the administration, scoring and analysis of PDDBI.
Must be used within 14 calendar days of the first date of service.
No telehealth.

97151 Outcome Measures

Units may be authorized under CPT 97151 by HNFS for each additional outcome measure (Vineland Adaptive Behavior Scales, Third Edition [Vineland-3]; Social Responsiveness Scale, Second Edition [SRS-2]; Parenting Stress Index, Fourth Edition Short Form [PSI-4-SF]; Stress Index for Parents of Adolescents [SIPA]) rendered by the authorized ABA supervisor (not delegated to the assistant).
HNFS will issue a separate authorization for these outcome measures with one unit per measure authorized.
For these outcome measure units, include modifier 99 on the claim form.

97153 Adaptive Behavior Treatment by Protocol:

Rendered by authorized ABA supervisors (or delegated to assistant behavior analyst) and BTs.
- School setting:
  - Rendered by ABA supervisor only for authorizations approved on or after May 1, 2021.
    - Must be approved through the clinical necessity review process.
    - Services are focused, time-limited, and in accordance with the requirements of the ACD.
  - Authorizations issued prior to May 1 with BTs approved to render in the school setting may continue until expiration.
May not exceed 32 units per day or 160 units per week.
15 minutes per unit.
No telehealth.

97155 Adaptive Behavior Treatment by Protocol Modification:

Rendered by authorized ABA supervisors (or delegated to assistant behavior analyst).
One session per month must be rendered by ABA supervisor.
- As of Aug. 1, 2021, subject to 10% penalty on all ABA claims for a beneficiary’s entire six-month authorization if not met.
- Ten percent penalty may be waived if no CPT 97153 services were rendered within the calendar month.
Team meetings and Individualized Education Program (IEP) meetings excluded.
May not exceed eight units per day.
Fifteen minutes per unit.
No telehealth.

97156 Family Adaptive Behavior Treatment Guidance:

Rendered by authorized ABA supervisor (or delegated to assistant behavior analyst).
May not exceed eight units per day.
Fifteen minutes per unit.
First session of either CPT 97156 or 97157 must occur within 30 calendar days of initial and subsequent treatment authorizations.
Six parent/caregiver sessions every six months (CPT 97156 and/or 97157).
After first six-month authorization period, may be rendered via telehealth if authorized. Specific criteria applies. See our ABA Service Locations page for details.

97157 Multiple-Family Group Adaptive Behavior Treatment Guidance:

Effective Aug. 1, 2021. (Beneficiaries are not eligible for this code until the next authorization period that occurs on or after Aug. 1, 2021. Requests submitted prior will be cancelled.)
Rendered by ABA supervisor (or delegated to assistant behavior analyst).
May not exceed six units per day and eight participants per group. May only be used in an office/clinic setting.
Fifteen minutes per unit.
First session of either CPT 97156 or 97157 must occur within 30 calendar days of initial and subsequent treatment authorizations.
Six parent/caregiver sessions every six months (CPT 97156 and/or 97157).
No telehealth.

97158 Group Adaptive Behavior Treatment by Protocol Modification:

Effective Aug. 1, 2021. (Beneficiaries are not eligible for this code until the next authorization period that occurs on or after Aug. 1, 2021. Requests submitted prior will be cancelled.)
Rendered by ABA supervisor.
May not exceed six units per day and eight participants per group.
Fifteen minutes per unit.
No telehealth.

99366 & 99368 Medical Team Conference:

Effective Aug. 1, 2021. (Beneficiaries are not eligible for this code until the next authorization period that occurs on or after Aug. 1, 2021. Requests submitted prior will be cancelled.)
Rendered by ABA supervisor
Minimum three qualified health professionals from different specialties who have performed face-to-face evaluations or treatments with the beneficiary within the previous 60 calendar days. (See TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.6.2.7 for more information.)
CPT 99366 is medical team conference with beneficiary present; CPT 99368 is without beneficiary present.
Beneficiaries with an assigned Autism Services Navigator (ASN) (new beneficiaries after Oct. 1, 2021) must have the ASN present for the duration of the medical team conference for ABA providers to be paid.
HNFS will authorize one unit of CPT codes 99366 and 99368 on all treatment authorizations every six months.
Face to face or telehealth permitted. See our ABA Service Locations page for details.

Service Locations

Please review definitions/guidelines for home, clinics/centers, daycares, school settings, community settings, telehealth, and indirect services on our Locations for ABA Services page.

PARENT TRAINING

Effective Aug. 1, 2021, ABA providers are required to have parent training (CPT 97156 or 97157) initiated within 30 days of an approved treatment authorization and a minimum of six parent training sessions (CPT 97157, 97158) per authorization period.

GROUP SETTING

Effective Aug. 1, 2021, CPT 97157 and 97158 units may be authorized for up to six units per day for use by the authorized ABA supervisor (ABA supervisors may delegate CPT 97157 to assistant behavior analysts) with no more than eight beneficiaries or parents (see respective codes) in a group setting. For CPT 97158, ABA Supervisors must demonstrate in the treatment plan that the beneficiary has the prerequisite skills to learn in a group delivery format for ABA therapy.

PROGRAM SUPERVISION VS. MODIFICATION

Services under CPT 97155 cover adaptive behavior treatment with protocol modification where the BCBA-D, BCBA or assistant behavior analyst resolves one or more problems with the protocol (for example, evaluating progress, progressing programs, modeling modifications, probing skills). The oversight and supervision of BTs and assistant behavior analysts is required as clinically appropriate and in accordance with the Behavior Analyst Certification Board guidelines and ethics but are not billable under the ACD. Claims submitted for supervision may be denied or recouped.

Program Modification. Effective Aug. 1, 2021, ABA supervisors are required to render a minimum of one visit per calendar month of CPT 97155 (program modification) to each beneficiary.

WEEKLY UNITS

The weekly units authorized for CPT 97153 cannot be rolled over to other weeks. The week is defined as Sunday to Saturday.

MONTHLY UNITS

The monthly units authorized for CPT 97155, 97156, 97157 and 91758 cannot be rolled over to other months. The first month begins the day services are authorized to start and ends on the last date of that month. Each month thereafter is based on the calendar month. For example, if the authorization starts Feb. 10, 2021, then the first month is Feb. 10–Feb. 28, 2021, and the second month is March 1–March 31, 2021.

UNITS THAT COVER THE LENGTH OF THE AUTHORIZATION

Units authorized over the length of an authorization, such as for CPT 97151, 99366 and 99368, can be submitted during any month of the authorization period.

Note: CPT 97151 units authorized for treatment reassessment are specifically for preparing the reassessment during the last 60-days of the authorization period and must be used within 14 calendar days of the first date of service.

MEDICALLY UNLIKELY EDITS (MUES)

DHA determines the maximum number of units allowed to be billed per day for each CPT code. MUEs are fixed and claims will deny if they are exceeded.

ABA providers cannot request these MUEs be exceeded prior to rendering care.
If an MUE is exceeded, you may request a claim review after your claim has processed (supporting medical documentation required).

Note: The American Medical Association (AMA) published additional Category I codes for ABS, which also include CPT codes 97152 and 97154. At this time, these codes and procedures are not approved under TRICARE’s Autism Care Demonstration (ACD). See information below for code updates that were implemented on Aug. 1, 2021.

Claims Information/Billing Tips

In response to changes to TRICARE’s Autism Care Demonstration, we have updated our claims systems to allow for new guidance put in place. Please review these important billing tips to help you minimize rejected or denied claims when billing for applied behavior analysis (ABA) services.

TAXONOMY

All claims must include the HIPAA taxonomy designation of each provider type. These include:

103K00000X – Behavior analyst for master’s level and above
106E00000X – Assistant behavior analyst
106S00000X – BT
Other appropriate HIPAA taxonomy based on license/certification

NATIONAL PROVIDER IDENTIFIER

All claims must include the rendering provider’s name and National Provider Identifier (NPI) for processing.

As of July 1, 2021, providers new to the network must have an NPI in place and included in their application submission. Providers can verify their NPI record by visiting https://npiregistry.cms.hhs.gov.

RENDERING PROVIDER

To ensure proper claims processing, list the rendering provider in Box 24 of the 1500 claim form. For all CPT codes, list the rendering provider (i.e., ABA supervisor, assistant behavior analyst or BT) as the rendering provider in Box 24.

Per TRICARE policy and AMA CPT guidelines, assistant behavior analysts and BTs may not be listed as the billing provider or bill for any ABA services as they are not independent providers according to their certification. Assistant behavior analysts and BTs receive compensation from their authorized ABA supervisor.

SESSION TIMES

Include the start and end time of the session for all CPT codes on claims. Please use military time format (HHMM). (See below for concurrent billing guidelines.) Claims billed without session times on each line and in military format will reject and need to be resubmitted.

Document the session start and end times in one of the following locations:

For an electronic data interchange (EDI) claim, put the session times in Loop 2400 for each individual line note.
For XpressClaims, put the session times in each individual line note.

UNIQUE LINES FOR SERVICES BILLED

TRICARE requires every session of ABA services be identified as its own unique line on claims submitted. (See TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.4.) When billing for multiple services rendered on the same day by the same rendering provider, you must separate out sessions, even if the CPT code is the same. Claims billed with multiple sessions on one line will reject and need to be resubmitted.

Incorrect: Line one indicates 8 units of CPT 97153; the line note includes session times of 0800–0900 and 1300–1400.
Correct: Line one indicates 4 units of CPT 97153; the line note includes a session time of 0800–0900.
Line two indicates 4 units of CPT 97153; the line note includes a session time of 1300–1400.

MODIFIERS

TRICARE requires the use of specific modifiers to indicate patient presence and/or remote sessions. Adding a note such as “patient not present” or “patient with RBT” does not meet this requirement. Use the following modifiers as applicable:

HR – Family/couple with client present
HS – Family/couple without client present
GT or 95 – Parent/caregiver remote sessions
GT or 95 – Use with T1023 for remote outcome measure administration, when applicable
99 – Use with 97151 to identify outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA)

See below for concurrent billing guidelines.

PLACE OF SERVICE CODES

02 (Telehealth)
03 (School)
11 (Office/Clinic)
12 (Home)
99 (Other) – e.g., non-school daycare, community settings

Find additional information on location codes at CMS.gov and our ABA Service Locations page.

Concurrent Billing

Concurrent billing is excluded for all ABA codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. The correct rendering provider must be identified in Box 24J on the claim form. Medical documentation should clearly identify who was present during the session and the location, including all providers, the beneficiary and parents/caregivers, when applicable. Claims for concurrent billing that do not include the session times (see above) and the presence or absence of the beneficiary will deny. Document the required information in one of the following locations:

For an EDI claim, the notes should be in Loop 2400 for each individual line note
For XpressClaims, the notes should be in the individual line note

Concurrent billing modifiers

HR – Family/couple with client present
HS – Family/couple without client present

CONCURRENT BILLING CODES ALLOWED

CPT Codes	97151	97153	97155	97156	97157	97158
97151	N/A	N/A
97153	Yes	N/A
97155	No	No	N/A
97156	Yes	Yes	Yes	N/A
97157	Yes	Yes	Yes	No	N/A
97158	Yes	No	No	Yes	Yes	N/A

97153 and 97155: Concurrent billing is not permitted. Only one code should be billed when concurrent care services are performed.

97153 and 97156: Concurrent billing is permitted if the BT, assistant behavior analyst or ABA supervisor is working with the beneficiary (CPT 97153) and the ABA supervisor or a different ABA supervisor or assistant behavior analyst is conducting parent training (CPT 97156) and the beneficiary is not present.

97155 and 97156: Concurrent billing is permitted if the BCBA-D, BCBA or assistant behavior analyst is working with the beneficiary (CPT 97155) with or without the BT present and a different ABA supervisor or assistant behavior analyst is conducting parent training (CPT 97156), and the beneficiary is not present.

97151 and 91753 or 97156: Concurrent billing is permitted if the ABA supervisor or assistant behavior analyst is completing an element of the assessment (for example, direct time, report writing) under CPT 97151 and a different ABA supervisor, assistant behavior analyst, or BT is rendering CPT 97153 or 97156. The beneficiary can only be present for one code.

97157 and 97158: Concurrent billing is permitted if the ABA supervisor has delegated CPT 97157 to the assistant behavior analyst who is facilitating the parent group while the ABA supervisor is rendering CPT 97158 with a group of beneficiaries.

Electronic Funds Transfer

All network and non-network ABA provider claims must be submitted electronically. Effective Aug. 1, 2021, HNFS is required to reimburse ABA sole providers and ACD Corporate Services Providers (ACSPs) for ACD services via electronic funds transfer (EFT). Visit our Claims Submission page for more information.

If you are an ABA sole provider or ACSP who has not yet signed up for EFT, visit our EFT/ERA page to get started. New enrollments can take up to 45 days to process once all information is received.

Reimbursement Rates

Reimbursement rates are based on independent analyses of commercial and Centers for Medicare and Medicaid Services ABA rates, and vary by geographic locality.

Visit the Defense Health Agency's Applied Behavior Analysis Maximum Allowed Amounts page to view current rates.

Balance billing reminder: ABA providers may not bill the beneficiary more than 100% of the rates posted at https://www.health.mil/rates. The balance billing guidelines defined in the TRICARE Reimbursement Manual (Chapter 3, Section 1, paragraph 4.0) do not apply.

Penalties: Effective Aug. 1, 2021, providers are required to complete at least one direct session per month for 97155. HNFS must perform post-claims payment reviews to confirm compliance. Non-compliance will result in a 10% penalty on all ABA claims for the entire six-month authorization for that beneficiary.

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