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Autism Care Demonstration Billing Details

TRICARE has adopted the American Medical Association's new Current Procedural Terminology® (CPT) Category I codes for applied behavior analysis (ABA) services, effective for dates of service on or after Jan. 1, 2019. To learn how to submit electronic claims, visit our claims submission page.

The Category I CPT code transition details can be found in our Category I CPT Code Transition Archive.

Category III to Category I CPT Codes

Authorizations

All requests for services (initial and ongoing) submitted on or after Jan. 1, 2019, must specify Category I codes/units. HNFS will only authorize to what is documented in the treatment plan. Please update any treatment plan templates to ensure all recommendations are listed in units, not hours. ABA treatment plans submitted after Jan. 1 2019, without Category I codes/units will not be approved and an updated treatment plan will be requested. 

Claims

All claims for ABA services rendered on or after Jan. 1, 2019, must include Category I CPT codes. Claims will be processed based on the conversion table above. Continue to bill using Category III codes for ABA services rendered prior to Jan. 1, 2019.

ABA Billing Codes

Use this crosswalk for assistance with determining appropriate billing codes when providing services under the Autism Care Demonstration. 

Two-week period (97151): An authorization for 97151 will be provided for the full service period on the authorization. The 16 units must be rendered within a two-week (14 calendar day) window. If this service is not rendered within 14 days, the claim will be denied.* Any unused units will not transfer to the next assessment period.

*If you or the beneficiary/parent experience extenuating circumstances that prevent you from meeting the 14 calendar day window, but the care was provided within 21 calendar days, you may request a claim review by following our claim appeal process. (Extenuating circumstances do not include missed appointments due to convenience, scheduled vacations, etc.) 

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, 2019, then the first month is Feb. 10–Feb. 28, 2019, and the second month is March 1–March 31, 2019. 

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

Category I CPT Code Billing

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 

Concurrent billing: Concurrent billing is excluded for all ABA 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. 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 

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. 

Team meetings: Team meetings are no longer 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. 

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


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). As of Jan. 1, 2019, supervision of the assistant behavior analyst and behavior technician, such as treatment fidelity checks and feedback, is not covered under the Autism Care Demonstration. 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.  

Cost-shares/copayments: 

  • 97151 is approved for 16 units delivered within a two-week period. A single copayment or normal program cost-share will be assessed for all occurrences of the 97151 within the two week window. 
  • For 97153, 97155 and 97156, a single copayment or normal program cost-share will be assessed per day. 
  • If 97151 and another code (97153, 97155, 97156) are billed on the same date of service, only one copayment or normal program cost-share will be applied per day.

Session notes: The rendering provider must complete medical documentation for all sessions at the time of service. Please see our medical documentation page for more information on the requirements for session notes

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

Exclusions: The TRICARE Operations Manual, Chapter 18, Section 4, Paragraph 19.0 defines excluded items under the ACD. These include, but are not limited to, training of behavior technicians, indirect tasks (for example,  emails, phone calls, office and therapeutic supplies), telehealth or remote services unless related to T1023, restraint procedures, transportation between services, educational/academic and vocational services, group ABA services, and respite or custodial care. 

Concurrent billing

Concurrent billing is excluded for all ABA 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. 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:

  • EDI claims: The notes should be in Loop 2300 for the header notes and in Loop 2400 for each individual line note.
  • 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 Guidance

List the rendering provider in Box 24 of the 1500 claim form to ensure proper claims processing. 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 Category III and Category I 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

Note: The GT modifier must be present on all claims where the T1023 code was implemented via telehealth.

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.

For dates of service on or after Jan. 1 2019, rates by geographic locality for the Category I CPT codes will be provided.

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