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Understanding the New Adaptive Behaviors CPT Codes

The American Medical Association CPT® Editorial Panel has released eight new Category I codes and two revised Category III codes for billing ABA therapy services or “adaptive behavior” services. These codes will go into effect on January 1, 2019.

Why is this Important?

Applied Behavioral Analytics (ABA) billing and coding have evolved significantly over time. For many years, ABA therapy providers and receivers were plagued with inconsistent coverage and reimbursement policies. Due to this, a Coding Change Application (CCA) was submitted to the American Medical Association (AMA) in 2013 to standardize the billing and repayment processes for adaptive behavior services.

After this application, the  AMA CPT Editorial Panel developed a set of temporary Category III codes for ABA billing that were released in October of 2013 and came into effect in July of 2014. These new codes helped standardize the billing and repayment processes for providers offering ABA therapy.

The codes released in 2013 were significant, they marked the first step in creating a standardized ABA billing process, however, they did not mark the end of this process.

The Difference Between Category I and Category III CPT Codes

CPT codes are split into two categories:

  • Category III codes are temporary codes that allow the AMA to collect data on emerging technology, services, and procedures. Category III codes are helpful in determining how widely used services that are being submitted to the CPT Editorial Panel are.
  • Category I codes are permanent numerical codes that are five digits long and can be used with CMS and any other third party payer.

After the temporary Category III was released in 2013, a working group consisting of ABAI, APBA, Autism Speaks, the BACB, and other stakeholders was created to receive feedback and revise the code set.

From 2014 to 2016, the ABA working group completed extensive research through interviews and surveys to finalize the utilization of Category III Adaptive Behavior Codes by providers in the U.S.

A revision of the CCA was submitted by the ABA working group in 2016. This revision requested Category I codes for adaptive behavior services. ABAI, APBA, and Autism Speaks were invited to present their code change proposal at the 2017 CPT Editorial Panel meeting in New Orleans. During this meeting, the editorial panel approved eight Category I codes and revised two Category III codes. These codes will take effect on January 1, 2019.

The New 2019 ABA CPT Codes

The Category I codes are:

  • 97151: Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
  • 97152: Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes.
  • 97153: Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, every 15 minutes.
  • 97154: Group adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional,   with two or more patients, every 15 minutes.
  • 97155: Adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, which may include simultaneous direction of a technician, face-to-face with one patient, every 15 minutes.
  • 97156: Family adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), every 15 minutes.
  • 97157: Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, every 15 minutes.
  • 97158: Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, face-to-face with multiple patients, every 15 minutes.

The revised Category III codes are:

  • 0362T: Behavior identification supporting assessment, every 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:
    • administered by the physician or other qualified healthcare professional who is on site;
    • with the assistance of two or more technicians;
    • for a patient who exhibits destructive behavior;
    • completed in an environment that is customized to the patient’s behavior.
  •  0373T: Adaptive behavior treatment with protocol modification, every 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:
    • administered by the physician or other qualified healthcare professional who is on site;
    • with the assistance of two or more technicians;
    • for a patient who exhibits destructive behavior;
    • completed in an environment that is customized, to the patient’s behavior.

To see how the new Category I codes relate to the old temporary Category III codes, check out these adaptive behaviors crosswalk created by BACB. These new code changes will directly affect ABA providers, practices, and recipients as they are adopted by healthcare plans. WebABA will have these new codes ready to use on January 1, 2019. Check out how we can help you streamline your ABA billing.