Understanding ABA Therapy Billing and CPT Codes
There are a lot of things to keep in order when it comes to running your own ABA therapy practice. From keeping your credentials and certifications up-to-date to managing your staff, plus all the record-keeping that must be taken care of, there is more than enough to make anyone feel a bit overwhelmed at times.
A couple of different topics regularly come up when we work with ABA professionals because they require a constant effort to keep up with.
Two of those frequent topics discussed are current procedural terminology (CPT) codes, which are the primary guidelines for billing for therapy services, as well as split codes, which arise when a patient receives treatment from more than one qualified healthcare professional (QHCP) during a session.
There are a few general things to keep in mind when working through these billing aspects.
General Guidelines for ABA Therapy Billing
1. The 16 CPT codes (0359T-0374T) are divided into two general categories.
The first category of codes mirrors the first stage of developing an ABA therapy plan: assessment. The initial behavior identification assessment, identified by code 0359T, has two follow-up categories, observational and exposure behavioral assessments.
These two steps in the assessment process can each be divided into two separate codes, depending on how long the treatment session lasts. The observational component can be billed under code 0360T for any session that lasts less than 30 min and under 0361T for any that goes longer.
The same holds true for the exposure behavioral assessment stage and code numbers 0362T and 0363T.
The remaining codes, from 0364T to 0374T, all cover various treatment services. Like the steps in the assessment stage, some treatments can be billed under two separate codes depending on the length of the session.
Three codes, 0370T-0372T, all cover treatments that are not subject to being timed. Two of these, 0370T and 0371T, are treatments that involve providing guidance to families in both single-family and multiple family settings, without patients being present.
The final two codes, 0373T and 0374T, are tied to a single stage of treatment that is billed differently depending on the amount of time that goes into each visit.
This step, exposure adaptive behavior treatment with protocol modification, gets billed under the former code for all sessions that last less than an hour. For every additional half hour, the latter code is used for billing purposes.
2. The person performing a treatment service is another coding indicator.
While only a QHCP can submit billing for ABA therapy, there are a number of support staff that play a part in the treatment of any given patient. The different CPT codes used in ABA therapy billing do have direct correlations to the professional or paraprofessional involved.
The initial assessment, under code 0359T, is performed by a QHCP. The remainder of the assessment procedures and their corresponding CPT codes are all carried out by a technician.
Treatment codes that are related to the technicians in therapy, 0364T-0367T, 0373T and 0374T, all involve direct work with patients. There are no billing codes concerning the families of patients and technicians.
All remaining codes, 0368T-0372T, cover treatment given by the QHCP in charge of the team attached to each patient.
As a corollary of the information above, the only treatment steps that involve family members or multiple patients’ families that are billed are ones carried out by a QHCP.
3. Split codes cannot result in “double billing”.
Keeping track of all the details involved with correctly billing according to the CPT codes can be difficult enough when there is just one type of treatment a patient is receiving in a given session.
Multiple treatments involve not only the possibility of different CPT codes but also coordination between professionals who may not always work with the same organization.
Double billing is when more than one provider works with a patient during a given time frame and they both bill the patient for the full amount of time. There are two general paths that can be taken to resolve this type of situation.
Whether there is a “team therapy” approach that is being taken for a particular patient or not, the multiple therapists who worked with the patient can’t all claim the time covered. One option is for a single therapist to bill for the entirety of the session, if it can be decided that they were in a leading role and others acted in more of a support role.
The second option involves splitting the time evenly into separate billing codes. For example, a session involving a Speech Language Pathology (SLP) and an ABA therapist that lasts 60 minutes, would be divided into 30-minute sections for each treatment.
ABA Therapy CPT Codes
As we know, medical billing and coding is a very complex process. Adding to this complexity in the ABA world is the fact that CPT codes are still Category III (temporary) and are thus not nationally recognized. When coupled together, even the most attentive billing team can experience the occasional misstep.
What are Category III ABA CPT Codes?
The American Medical Association (AMA) released a set of temporary Current Procedural Terminology (CPT) billing codes for ABA evaluation and treatment services several years ago to aid payers and practitioners in their development of billing systems for emerging ABA therapy.
There has been some confusion in regards to these codes, especially the Initial Untimed Behavior Identification Assessment code (0359T), as well as the Observational Behavioral Follow Up assessments codes (0360T and 0361T respectively).
Unfortunately, the use of these codes has not been uniform across services and insurances, so when deciding which billing codes to use, it is vital you only use those for which you have written approval for from the insurer’s health plan. Some carriers have adopted the temporary CPT codes, while others have/will not.
Again, attend to the codes in your contracts and the applicable rates. Organizations such as APBA, ABAI, BACB, and Autism Speaks are working on legal proposals to help alleviate some of these issues, but the codes will likely remain in place for a few more years before any changes will occur.
Rates for CPT Codes
Since CPT Category III codes are temporary, they have no nationally recognized value. Currently, each insurance company negotiates reimbursement rates by geographic region.
As an ABA practitioner, you should not file reimbursement claims until you are able to verify that the insurer for your patient has appropriate coverage and accepts these codes.
Top ABA Therapy CPT Codes
The American Medical Association describes 0359T as:
“Behavior identification assessment by the physician or other qualified healthcare professional (QHCP), face-to-face with patient and caregiver(s). Includes administration of standardized and nonstandardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report.”
Generally, all clients will receive an initial assessment (0359T), which will be reported once and is estimated to take 90 minutes of QHCP time—though it could take more or less time. However, code 0359T is not a time code and cannot be billed in increment. Insurers usually develop plan coverage payment to the “typical” time allotted for a service. Because office time may be required to effectively develop a treatment plan and report, these costs should be included in a practice’s expenses.
Additionally, 0359T may be used to report a reassessment. This is usually required after the success or failure of a current treatment, which requires new or revised treatment goals. Code 0359T may also be reported for an assessment required for early intensive behavioral intervention (EIBI).
Depending on the results of this initial assessment, the QHCP will decide whether or not additional assessments are required and will develop a treatment plan accordingly. This may mean directly proceeding to a treatment for uncomplicated problems.
Observational Behavioral Follow-up Assessment Codes 0360T and 0361T
Once the initial assessment has taken place and a treatment plan developed, all clients will receive an observational behavioral follow-up assessment is coded as either 0360T or 0361T (for an ABLLS, AFLS, and one BCaBA).
0360T is identified as:
“Observational behavioral follow-up assessment. Includes physician or other qualified healthcare professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient.”
0361T is identified as:
“Observational behavioral follow-up assessment. Includes physician or other qualified healthcare professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (list separately in addition to code for primary service).”
Code 0359T may be followed by procedures 0360T and 0361T by technicians who are directed by a QHCP. This data collected during these follow up sessions are utilized by the QHCP as baseline data and are used to help develop specific behavioral goals for the patient’s treatment plan.
Code 0360T can only be reported once per day for the first 30 minutes of a technician’s face-to-face with a patient, while code 0361T can be reported in multiple units. However, please be aware that the insurer may cap the frequency of 0361T.
Make sure to adequately detail the benefits of treatment.
Crosswalk available for CPT codes from ABAI
A workgroup comprised of representatives from the Association for Behavior Analysis International (ABAI), Association of Professional Behavior Analysts (APBA), Autism Speaks, and the Behavior Analyst Certification Board (BACB), as well as providers and health plans has learned that some payers are utilizing a blend of HCPCS codes with Category III CPT codes for reporting ABA services, while others are not utilizing the Category III codes at all.
Over the past year, feedback from payers and providers across the country indicated that crosswalk information would be extremely useful for achieving consistency in utilization and implementation of–and ultimately in establishing valuation and reimbursement rates for–the new codes.
A crosswalk chart is available (https://www.abainternational.org/media/109996/Crosswalk.pdf). It indicates the most common HCPCS and CPT codes that have been or are being utilized by payers to report ABA services. It is organized by the essential elements of ABA services, as indicated by the BACB. Those services include assessment and reassessment, treatment plan development and revision, direct treatment of individual clients, supervision or direction of technicians by a professional behavior analyst or other Qualified Healthcare Professional (QHCP), family or caregiver training, and group treatment. The crosswalk chart also indicates which personnel must attend each service to report the new CPT codes, as well as applicable time increments.
This crosswalk information is designed to foster a greater understanding of how Category III codes were intended to be reported and should be used to encourage uniform reporting of ABA services across providers, payers, and states.
Common ABA Therapy Billing Mistakes
One of the best methods to avoid making common billing and coding mistakes is knowing what they are. WebABA knows that a lot of your time and effort is placed into the billing process and that the last thing you need is a denial. Here are a few tips to avoid those common mistakes that can lead to a claims denial.
Consider the following errors that are frequently made in the billing and coding processes:
- Incorrect patient identifier information. A minor mistake like a misspelled name can easily lead to a denial. Your billing team should be detail oriented and ensure the patient’s name is spelled correctly, date of birth and gender are correct, policy number is valid, their relationship to the insured is accurate, and diagnosis codes match the procedure performed. Primary insurance should also be noted, as well as any group numbers, if necessary.
- Failing to verify patient’s insurance coverage. ABA therapy coverage varies by insurer so it is vital that your billing specialist(s) verify if services are covered or if coverage is terminated. It’s also important to make sure that maximum benefit (cap) has not been met. Health insurance can change at any time, therefore it is essential to constantly confirm coverage—a proactive approach can save your billing department from headaches later on.
- Duplicate billing. This mistake is often the result of human error; whether re-submitting a claim without effectively following up with the insurer or canceling a session or test without removing it from a patient’s account. Your claims billing team should have a system set in place, which should include proper coding of services and applicable modifiers, to evaluate potential duplicates. Suspicious entries will contain duplicate information such as:
- HIC number
- Provider number
- From and through the date of service
- Type of service
- Procedure code (and modifier)
- Place of service
- Amount billed
- Not meeting the deadline. Even if your claim is properly documented and completed, but you fail to submit it within the deadline window, it’ll likely be denied. The clock usually starts on the date the service was provided to the patient or the “From” date on the claims form. Deadlines vary by payer, with Medicaid allowing a full year to submit from the day of service to commercial insurers like UnitedHealthcare only allowing 90 days. It’s a best practice to have this information handy so you don’t run the risk of missing a due date and it’s also vital to understand what supporting documentation is needed to receive reimbursement in case you need to appeal in a timely manner.
- Failure to obtain a referral or prior authorization. As coverage varies by insurer, some payers will require that you obtain a referral or prior authorization before providing services or performing a procedure. Usually, it is the primary care physician who issues the referral and the payer who provides the prior authorization. Remember, this still does not guarantee payment. Services and submitted claims must be: supported by medical necessity, filed within the proper timeline, and submitted by the provider noted in the referral or authorization.
- Illegible documentation. Billing and coding errors can occur from something as simple as sloppy handwriting and documentation. If your billing team is unable to properly read the documentation, they may inadvertently assign the wrong CPT code, undercode a patient’s bill, or perform some other mistake. Ask your therapists and other healthcare providers to write neatly and correctly.
- Coding issues. As previously mentioned, the current CPT system can be a bit complicated for inexperienced and experienced billing specialists alike. Outdated codebooks, inputting the wrong CPT codes, point of service codes, coding mismatched treatment and diagnostic codes, or failing to input codes for all services performed by an ABA therapist, can all lead to your claim being denied. Coding issues can be directly tied to documentation; billing and coding must align with the services documented. Insufficient documentation, or none thereof, of any services, cannot be billed.
- Upcoding, undercoding, and unbundling. Upcoding is the entering of a higher-paying code on a claim for services not rendered. Upcoding increases the total amount a patient owes for receiving care and is illegal. Undercoding occurs when codes are left out of a bill. Providers might undercode to avoid audits or minimize a patient’s cost, which is also illegal and can lead to legal issues. Unbundling is when test and procedures are billed separately per component, which can increase the totals in comparison to their special reimbursement rates. These three practices are not legal nor ethically acceptable and should thus be avoided.
Avoiding ABA Therapy Billing Errors
There are a number of steps that can be taken to help prevent these basic, but costly errors, including:
- Support staff should verify patient and insurance information during the patient intake process. Insurance companies should be called before treatment to validate policy number and coverage.
- Coordinate with providers and the billing team to ensure that information is being handled adequately and being passed along appropriately. Determine who will compile the information, what personnel will be responsible for billing, and when that should be completed.
- Invest in training your staff or billing specialist on the latest codes and billing trends. Billing codes change over time because of healthcare regulations and other reasons. By keeping up with new codes and billing procedures, your team can be ahead of the curve.
- Stay vigilant and always make sure to double check all information. Thoroughly review all patient’s bills and documentation to ensure there is no vital data mission. Make sure to consult with therapists, physicians, and other medical professionals involved whenever you have a question about what should or shouldn’t be billed.
- Follow up on claims to help you avoid errors and create duplicate billing. Representatives working on the claims might be able to provide you with specifics to resubmit a claim before it gets denied.
WebABA can help you deal with the pressures of billing and understanding CPT codes.
Insurance companies can be challenging to work with; that’s why you need a partner that can help you to catch mistakes that the insurer, or even your own billing department, may make.
We follow up with insurance companies and funding sources to ensure that everything is paid correctly and authorization does not end prematurely. Because cash flow is the life of your clinic, we work hard to make sure that you have a steady stream of reimbursements coming in.
Insurance companies usually lag when it comes to payments, especially when there are changes to regulations and coding within the field. Amvik Solutions can stay on top of every change so you don’t have to worry.
- Electronic claim submission whenever possible or paper claim submission if required by the funding source
- Unpaid and denied claims follow up with insurance companies and funding sources
- Patient responsibility invoicing and follow up
- Claims follow up through the collection agency
- Client eligibility and benefit verification
- Regional Center co-pay/co-insurance coordination
- Comprehensive reporting – account ledger & claims denial report including an action trail documenting follow up the correspondence with insurance companies and funding sources