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Autism Care Demonstration Billing

To ensure proper claims processing, list the rendering provider in Box 24 of the 1500 claim form. For one-on-one services provided list the assistant behavior analyst or behavior technician as the rendering provider in Box 24. For all other services, list the authorized ABA supervisor in Box 24 for the claim to be eligible for reimbursement. 

The CPT codes do not allow assistant behavior analysts or behavior technicians to bill for any ABA services as they are not independent providers according to their certification. TRICARE is following the billing guidance for ABA specified in the AMA's CPT Assistant as well as TRICARE policy regarding provision of care by supervised trainees, which is what assistant behavior analysts and behavior technicians are. Assistant behavior analysts and behavior technicians receive compensation from the authorized ABA supervisor.

All claims must include the HIPAA taxonomy designation of each provider type. The designations to be used include:

  • 103K00000X – Behavior analyst for master’s level and above
  • 106E00000X – Assistant behavior analyst
  • 106S00000X – Behavior technician

Telemedicine

Effective March 31, 2020, through the end of the national emergency period, the Defense Health Agency has expanded telemedicine options allowed under TRICARE's Autism Care Demonstration. In addition to outcome measures, ABA supervisors and assistant behavior analysts may provide parent/caregiver guidance telehealth. Specific exclusions apply. Providers are responsible for understanding TRICARE's policy revision and how to manage authorizations during this emergency period. 

TRICARE will allow for Current Procedural Terminology (CPT®) code 97156 for synchronous (two-way audio and video) telehealth delivery, when performed by ABA supervisors (BCBA-Ds, LBAs, BCBAs) or assistant behavior analysts (BCaBAs, QASPs) and billed with the GT modifier and place of service 02. Behavior technicians cannot render 97156 services.

Services billed under 97151, 97153 and 97155 remain prohibited for delivery via telehealth, per TRICARE Operations Manual, Chapter 18, Section 4. During the emergency period, units for 97156 are unlimited; however, there must be an approved authorization on file for claims to pay. No changes are required for existing authorizations.  

TRICARE is waiving copayments and cost-shares for covered audio-only or audio/video telemedicine rendered by network providers on or after May 12, 2020. This waiver applies to covered in-network telehealth services, not just services related to COVID-19. Beneficiaries who seek telehealth from non-network providers are liable for their regular copayment or cost-share. 

Note: Audio-only services are not allowed under the Autism Care Demonstration.

See also:  

Details

Note: The American Medical Association (AMA) published additional Category I codes for adaptive behavior interventions which include 97152, 97154, 97157 and 97158. These codes and procedures are not approved under TRICARE’s Autism Care Demonstration. 

Sole/tiered:

  • Sole: BCBA-D, BCBA, Assistant Behavior Analysts delivering direct 1:1 services will bill as the rendering provider with 97153.
  • Tiered: Behavior technicians delivering direct 1:1 services will be billed as the rendering provider with 97153.
    Authorization requests do not need to differentiate between sole and tiered for 97153. ABA providers should recommend the total number of units for 97153 in their treatment plans. 

Session times: ABA providers must include the start and end time of the session for all CPT codes on the claim (see below for concurrent billing guidelines). Claims may be denied if the session times are not included. Document the session start and end times in one of the following locations:

  • For an EDI claim, the notes should be in Loop 2300 for the header notes
  • For an EDI claim, the notes should be in Loop 2400 for each individual line note
  • For XpressClaims, the notes should be a header or line note 

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

Monthly units: The monthly units authorized for 97155 and 97156 cannot be rolled over to other months. The first month begins the day services were 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, 2020, then the first month is Feb. 10–Feb. 28, 2020, and the second month is March 1–March 31, 2020. 

Medically Unlikely Edits (MUEs): DHA determines the maximum number of units allowed to be billed per day for each CPT code. The crosswalk defines the daily MUEs for each CPT code. The 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, the ABA provider may request a claim review by following our claim appeal process and submitting medical justification for the exceeded MUEs. The hours listed are determined by DHA and can be located at www.health.mil

Team meetings: Team meetings are not reimbursable under the ACD. Please note, that 97155 is not reimbursable under the ACD for team meetings conducted with school personnel, including attendance at IEPs. This applies to all beneficiaries including those who are approved to receive services in the school setting. 

Program modification vs. supervision: 97155 covers 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 behavior technicians 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 Autism Care Demonstration.  

Telehealth: Remote or telehealth services are not permitted for 97151, 97153, 97155, and 97156 (see above for temporary 97156 exception). Telehealth is permitted for T1023. Providers must bill using the GT modifier and place of service “02” for any teleheath services. 

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, 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 2300 for the header notes
  • For an EDI claim, the notes should be in Loop 2400 for each individual line note
  • For XpressClaims, the notes should be a header or line note 

Concurrent billing modifiers:

  • HR - Family/couple with client present
  • HS - Family/couple without client present

Billing codes:

  • 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 behavior technician is working with the beneficiary (97153) and the BCBA-D, BCBA or assistant behavior analyst is conducting parent training (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 (97155) with or without the behavior technician present and a different BCBA-D, BCBA or assistant behavior analyst is conducting parent training (97156), and the beneficiary is not present.
  • 97151 and 91753, 97155, 97156: Concurrent billing is permitted if the BCBA-D, BCBA or assistant behavior analyst is completing an element of the assessment (for example, direct time, report writing) under 97151 and a different BCBA-D, BCBA, assistant behavior analyst, or behavior technician is rendering 97153, 97155 or 97156. The beneficiary can only be present for one code. 

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 learn more.

Network provider rates may be discounted from the maximum allowable charge based upon the terms of your network agreement. There are benefits to being a network provider. The beneficiary pays less out of pocket when they see a network provider. In addition, network providers are listed on our provider directory and referrals, by our staff, are made to network providers.

T1023 rate:

  • Dates of service prior to May 1, 2019: For BCBAs submitting claims for T1023, reimbursement shall be the geographically adjusted reimbursement methodology for CPT code 96102. The CMAC rates can be found at https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/CMAC-Rates. Select the “Procedure Pricing” link, click accept, and then complete Steps 1 and 2 (your geographic information and CPT code 96102) and click submit. Then scroll down to the table for non-facility/non-physician.
  • Dates of service on or after May 1, 2019: Refer to the T1023 rate at www.health.mil/rates

 

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