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Autism Care Demonstration: Understanding Outcome Measures

Friday, December 3, 2021

Outcome measures are an important component for treatment planning and progress evaluation for those diagnosed with autism spectrum disorder. Under TRICARE’s Autism Care Demonstration (ACD), the following outcome measure scores must be submitted to the regional contractor before services under the ACD can be authorized: 

  • Pervasive Developmental Disorder Behavior Inventory (PDDBI) (parent/teacher, when applicable), 
  • Vineland, 3rd Edition (Vineland-3), 
  • Social Responsiveness Scale, Second Edition (SRS-2), and 
  • Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF) (0–12 years old) or the 
  • Stress Index for Parents of Adolescents (SIPA) Profile Form (11–19 years old). 

Who can complete? The treating applied behavior analysis (ABA) supervisor will complete the PDDBI as part of the initial assessment and at each six-month reassessment process. The other outcome measures can be performed by the ABA supervisor when prior authorized by HNFS. HNFS may authorize beneficiaries to other ABA providers with the ability to complete all additional outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA). The treating ABA provider may request authorization to complete the next cycle of outcome measures available for the beneficiary if they complete all required measures within the access standards. Due to overlapping CPT® codes (97151) for assessments, reassessments and outcome measures, HNFS authorizes separately for outcome measures. Prior authorization is required. 

What are some tips for successful submission? 

  • The teacher PDDBI must be completed by the ABA supervisor (may not be delegated).
  • Ensure scores are within the publisher’s limits. Do not imbed scores into treatment plans or other documents. TRICARE requires the full publisher score report only or hand-scored summary score sheet(s). HNFS will not request the protocols, questions or other assessment materials. 
  • Submit the parent PDDBI for the first treatment authorization (assessment) and the parent and teacher PDDBI for all subsequent treatment authorizations.
  • The name of who answered the questions in the measure (name of respondent) and their relationship to the beneficiary must be included. Requests for authorization will not be processed without these data points.  
  • The Vineland-3, SRS-2 and PSI-4-SF/SIPA must be completed within the last 90 days of the outcome measure cycle.

How to submit: The ABA provider or ASD-diagnosing provider can either attach a copy of the outcome measure scores (and related data points) online using CareAffiliate® (log in required; use request type P177 – ACD ABA Treatment Authorization for PDDBIs submitted with treatment plans and P175 – Outcome Measure Authorization for all other measures) or fax to HNFS at 1-877-910-0945. Billing tip: Use modifier ‘GT’ or ‘95’ with T1023 to identify remote outcome measure administration; use modifier ‘99’ with 97151 to identify outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA) vs. assessments.

How are the PSI-4 & SIPA scores used? The PSI-4-SF and SIPA are standardized, reliable measures of stress and family dynamics; however, the scores are not factors for treatment planning or coverage determination. Rather, providers should use the scores to identify where additional support resources may benefit both the family and the beneficiary. The scores are not intended to diagnose dysfunction in the parent/adolescent relationship or as screening tools for parental mental health. 

Please visit our Outcome Measures page for additional information and printable resources.