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Autism Care Demonstration: Exclusions

Overview

Services excluded from the Autism Care Demonstration (ACD) are not reimbursable and will not be authorized. Please refer to TRICARE Operations Manual Chapter 18, Section 4 for complete details.

In accordance with new ACD requirements, we are increasing the number of medical record documentation reviews performed on all applied behavior analysis (ABA) sole providers and Autism Corporate Services Provider (ACSP) provider groups. Visit our Compliance & Audits page for details. 

Be sure to familiarize yourself with ACD exclusions to minimize documentation review errors and penalties.

Key Exclusions by Category 

ABA providers are not to bill for the following excluded services, per ACD guidelines (not all-inclusive)
 

Telehealth

  • Asynchronous telehealth services.
  • ABA services provided remotely through internet technology or through telemedicine/telehealth, except for:
    • Current Procedural Terminology (CPT®) code 97156 after the first six-month authorization and if telehealth was authorized.
    • CPT 99366 and 99368 (medical team conference), if authorized. Audio only not allowed.

See our ABA Service Locations page for details. 
 

Location

  • Services outside of the home, clinic, office, school, or telehealth. Certain community settings such as sporting events, camps and other settings are also excluded. 
  • ABA services while the beneficiary is at another medical appointment to include another family member’s appointment.
  • Behavior technician (BT) or assistant behavior analysis services in the school setting. Current authorizations approved prior to May 1, 2021, can continue through the end of the authorization. 

See our ABA Service Locations page for details. 
 

Type of service, goals

  • ABA services in the school setting as a shadow, aid, or support to the beneficiary. ABA services in the school setting are limited to the role of the ABA supervisor targeting a specific behavior excess or deficit for a limited duration. 
  • Goals targeting activities of daily living (ADLs). Note: The principles of ABA (i.e., backward chaining, schedules of reinforcement, etc.) may be targeted as a goal of parent/caregiver guidance to introduce parents on how to teach ADLs outside of ABA services.
  • Educational ABA services, such as services typically provided through a school curriculum
  • Vocational ABA services 


Interventions, targeted symptoms

  • ABA services using any aversive techniques or restraints
  • Any interventions considered psychotherapy, including, but not limited to: 
    • Cognitive behavior therapy
    • Acceptance and commitment therapy
    • Prolonged exposure
    • Group psychotherapy, etc.
  • Symptoms and/or behaviors that are not part of the core symptoms of autism spectrum disorder (ASD), such as impulsivity due to attention-deficit/hyperactivity disorder (ADHD), reading difficulties due to learning disability, excessive worry due to anxiety disorder, etc.


Other activities

  • Supervision of BTs
  • BT training
  • Emails and phone calls
  • Report writing outside of what is included in the assessment code (CPT 97151)
  • Mileage/time to and from ABA services appointments (e.g., beneficiary’s house, clinic, or other locations)
  • Office supplies or therapeutic supplies (e.g., binders, building blocks, stickers, crayons, etc.)


Concurrent billing

  • Concurrent billing for all adaptive behvior services (ABS) Category I CPT codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. 

See our Billing page for details.


Other exclusions  

  • Group ABA services billed as one-on-one services
  • ABA services for diagnoses other than ASD
  • Educational/academic and vocational rehabilitation
  • ABA services that are written in the beneficiary’s Individualized Education Program 
  • Autism schools. If the school has a clinic setting, the clinic must have a separate Tax Identification Number in order for the setting to be eligible for reimbursement.
  • School tuition
  • Any two ABA providers authorized to provide treatment at the same time
  • ABA services provided by a clinic or agency owned by the beneficiary’s immediate family members 
  • ABA services provided directly by the beneficiary’s responsible adult 
  • Non-ABA services
  • Custodian, personal care and/or child care
  • Other non-medical services such as changing of diapers
  • Services when the beneficiary is sleeping
  • Durable equipment for which safety and efficacy have not been established, as described in 32 Code of Federal Regulations §199.4

 

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