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CPT® Code 97155 Requirements in the Autism Care Demonstration

Wednesday, February 28, 2024

Health Net Federal Services, LLC (HNFS) would like to remind applied behavior analysis (ABA) providers about TRICARE’s mandatory Autism Care Demonstration (ACD) requirement for monthly adaptive behavior treatment with protocol modification encounters. Authorized ABA supervisors must render a minimum of one encounter per month (cannot be delegated to assistant behavior analysts) for Current Procedural Terminology (CPT®) 97155 for their patients pre-authorized for treatment. If this requirement is not met, a claims penalty may apply.

Per TRICARE Operations Manual (TOM), Chapter 18, Section 4 guidelines, to meet minimum requirements, CPT code 97155 encounters must:

  • Have at least one encounter rendered by an authorized ABA supervisor (cannot be delegated to an assistant behavior analyst).
  • Allot 15 minutes per unit.

Mandatory monthly CPT code 97155 encounters must not:

  • Be a team or Individualized Education Program meeting.
  • Be provided through telehealth.
  • Exceed eight units per day.

Reimbursement Penalty

If the monthly CPT code 97155 encounter requirement has not been met, ABA claims submitted for the beneficiary’s entire six-month authorized treatment period will be subject to a 10% penalty. Exception: The 10% penalty may be waived if direct treatment wasn’t rendered in a calendar month.

For more information on ACD-related billing requirements, refer to TRICARE Operations Manual, Chapter 18, Section 4 or visit our Billing page.

Please note: This educational piece reflects existing process and requirements in effect since the implementation of TOM 85. There are no changes to these requirements in TOM 132.