Autism Care Demonstration: Exclusions
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 ACD requirements, we have increased 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):
- Asynchronous (one way) 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 codes 99366 and 99368 (medical team conference), if authorized.
- Audio-only not allowed.
See our ABA Service Settings page for details.
- Camps or sporting events
- 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
- ABA services in the school setting are limited to the role of the ABA supervisor (when authorized) targeting a specific behavior excess or deficit for a limited duration.
- School shadow/aide support is excluded. The ABA supervisor must be actively implementing approved treatment plan goals.
See our ABA Service Settings page for details.
- Goals targeting activities of daily living (ADL). The principles of ABA (such as, backward chaining, schedules of reinforcement, etc.) may be targeted in direct treatment as a goal that once mastered can be generalized for parent/caregiver goals under CPT code 97156 to introduce parents/caregivers to teaching ADLs outside of ABA services.
- Any target or goal that includes teaching how to complete or correctly complete an excluded task. Goal targets cannot involve the actual completion of an ADL or academic objective, but they can target core autism spectrum disorder (ASD) symptoms (for example, communication and social deficits, behavior excess) that occur as a part of the ADL or academic objective. Stimuli associated with ADLs can be used to work on core ASD symptom goal targets; however, direct instruction or correction about performing the ADL correctly, increasing accuracy or completing the ADL are excluded.
- Goals that address areas not related to core ASD symptoms of communication, social delay or restricted and repetitive behavior.
- Goals targeting symptoms and/or behaviors that are not part of core ASD symptoms, such as impulsivity due to attention-deficit/hyperactivity disorder (ADHD), reading difficulties due to learning disability, excessive worry due to anxiety disorder, etc.
- Opportunities where active delivery of services cannot occur.
- Goals targeting educational or vocational areas.
- Reading comprehension that is academic in nature and/or not related to core ASD symptoms.
- Items that are labeled social or communication-focused but still meet the definition of an ADL or academic objective (for example, will engage in socially acceptable levels of homework, will label the main character and plot of a book, will complete chores at a socially appropriate amount, etc.).
- Goals targeting specific motor actions or motor planning (for example, oral imitation, "will grip items using pincer grasp," "will walk up stairs," "will use sequence of movements," etc.). These will require modification or will not be covered.
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.
- Systematic desensitization
- Cognitive behavior interventions
- Supervision (direct or indirect) and training of Registered Behavior Technicians® (RBT®) and BTs.
- Emails and phone calls
- Report writing outside of what is included in the assessment code (CPT code 97151); Note: Discharge report writing is not a reimbursable service, as this is an indirect activity (report/summary writing)
- Mileage and drive time to and from ABA services appointments (for example, beneficiary’s house, clinic, or other locations)
- Purchase or creation of office supplies, therapeutic supplies or stimuli (for example, binders, building blocks, stickers, icons, etc.)
Concurrent billing for all adaptive behavior 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.
- Group ABA services billed as one-on-one services
- When recommending ABA treatment in the school setting, goals cannot overlap or duplicate services included 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.)
- 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, feeding, etc.
- Services when the beneficiary is sleeping
Note: If an excluded activity is documented in the progress note and there is no information to validate the time spent on the exclusion(s), the entire session is subject to recoupment.
CPT® is a registered trademark of the American Medical Association. All rights reserved.