Report ABA Therapy Services With Confidence

Know the ins and outs of adaptive behavior assessment and treatment to ensure proper billing.

Applied behavioral analysis (ABA) therapy is the most common therapeutic intervention for children with autism spectrum disorder (ASD). Autism is a condition characterized by varying difficulty with repetitive behaviors, social skills, speech, and non-verbal communication. ASD affects individuals uniquely. The extent to which an individual is affected, and in what ways they are affected, varies from highly functioning to severely challenged.

Four times more prevalent in boys than girls, ASD is not characterized by any racial, ethnic, or socioeconomic factors. According to a report published in 2021 by the Centers for Disease Control and Prevention, about 1 in 44 children identifies on the autism spectrum. Early signs of autism usually appear around age 2 or 3 years. Research indicates that starting early therapeutic intervention as soon as signs of autism are observed improves learning, communication, and social skills later in life for patients diagnosed with ASD. Here’s how to code ABA therapy for ASD.

Assess and Treat

ABA therapy was introduced in the 1960s by UCLA psychologists Ivar Lovaas and Robert Koegel. ABA therapy is rooted in the understanding of how behavior works and is affected by the environment, as well as how learning takes place individually. This therapeutic intervention is not limited to children on the autism spectrum; it also includes other development disorders.

Typically, a unique program or protocol is developed for each child with focus on decreasing problem behaviors and improving communication, attention, focus, memory, and academic skills. ABA therapy uses a multi-practitioner approach, usually incorporating both 1-to-1 teaching and teaching in a group and/or familial environment. It most commonly includes a Registered Behavior Technician (RBT) and a Board Certified Behavior Analysist (BCBA).

ABA therapy combines adaptive behavior assessments and adaptive behavior treatment. Adaptive behavior treatment addresses a patient’s specific target problems and treatment goals as defined by a provider in previous assessments. This treatment is based on principles including analysis and alteration of contextual events and motivating factors, stimulus consequence strategies and replacement behavior, and monitoring of outcome metrics. Goals of adaptive behavior treatment may include reduction of repetitive and aberrant behavior and improved communication and social functioning. Adaptive behavior skill tasks are often broken down into small, measurable units, and the patient practices each skill repeatedly until the skill is mastered. This treatment may take place in multiple sites and social settings.

The common CPT® codes used to report these services are 97151, 97152, and 0362T for adaptive behavior assessments and 97153-97158 and 0373T for various adaptive treatment services.

Assessment

97151    Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician’s or other qualified health care 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 health care professional, face-to-face with the patient, each 15 minutes

0362T    Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient’s behavior.

Treatment

97153   Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes

97154   Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes

0373T    Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient’s behavior.

97155   Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes

97156   Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes

97157   Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes

97158   Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

Commonly used modifiers in ABA therapy are as follows:

• HM/HN to indicate a service performed by an RBT
• HO/HP to indicate a service performed by a BCBA or other qualified healthcare professional (QHP)
• BA to indicate a service performed by a technician (used by various state Medicaid plans)

Some state Medicaid plans require the use of HCPCS Level II codes H2014 for skills training and development and H2019 for therapy services. The interpretation of these HCPCS codes varies from state to state but, in general, H2014 represents behavior analysis by a RBT and H2019 is reported by the BCBA. Review of specific state Medicaid guidelines to determine appropriate reporting of these services is recommended.

Understand Protocol

To accurately report ABA therapy, it’s important to understand protocol modification and the distinction between implementing the established protocol and revising and/or adjusting the protocol. Protocol modification includes but is not limited to:

• Adjustments to certain components of a patient’s protocol, such as changes to treatment targets and goals, prompts, and instructions;
• Observation to determine if the established protocols are effective for the patient;
• Active direction of an RBT while they are delivering a service to the patient to correct errors in implementation of the protocol or training the RBT on modified protocols; and
• BCBA implementation of the protocol with the patient to determine if adjustments are needed or to evaluate a modified protocol.

CPT® codes identify treatment by protocol (97153, 97154), guidance (97156-97158), and with protocol modification (97155). According to the CPT® Adaptive Behavior Treatment guidelines (not verbatim):

• Adaptive behavior treatment by protocol and group adaptive behavior treatment utilizes a treatment protocol designed in advance by the physician or other qualified healthcare professional, who may or may not provide direction during the treatment.
• Family adaptive behavior treatment guidance and multiple-family group adaptive behavior treatment guidance involves identifying potential treatment targets and training guardian(s)/caregiver(s) of one patient or multiple patients to implement treatment protocols designed to address deficient adaptive or maladaptive behaviors.
• Group adaptive behavior treatment with protocol modification monitors the needs of individual patients and adjusts the treatment techniques during the group sessions, as needed. In contrast to group adaptive behavior treatment by protocol, protocol adjustments are made in real time rather than for a subsequent service.
• Adaptive behavior treatment with protocol modification; the physician or other qualified healthcare professional resolves one or more problems with the protocol and may simultaneously direct a technician in administering the modified protocol while the patient is present. Treatment modification involves changes to the client’s protocols, targets and goals adjusting therapy to tailor fit the individuals needs as their skills change and progress.

Follow Payer Rules

Payer rules vary concerning which providers can report which service(s). CPT® guidelines allow a BCBA to bill all the CPT® codes listed above, provided the required elements are contained in the documentation. According to ABAInternational.org, 97155 should be billed when a BCBA conducts direct treatment with the client to observe changes in behavior or troubleshoot protocols or when the BCBA directs the technician in implementing a new or modified treatment protocol. Conversely, an RBT can only bill codes 97152, 97153, and 97154. These rules may vary from payer to payer.

Payer rules also vary on allowance for concurrent billing, which refers to different services provided to the same patient at the same overlapping clock time. For instance, an RBT sees a patient from 1 pm to 3 pm and bills the payer eight units of 97153. The BCBA observes the RBT’s implementation of a modified protocol for the same patient for the same clock time and bills eight units of 97155. Some payers will allow both the RBT and BCBA to bill under these circumstances and some will not. Always check payer guidelines to validate specific coverage.

Document Therapy Sessions

Documentation for ABA therapy can range from well-organized data sheets containing measurements of established goals and/or behaviors to electronic session notes to handwritten documentation. Regardless of the type of documentation, the required elements remain the same. Required documentation elements establish medical necessity and ensure accurate coding of ABA therapy. Each session note should minimally include the following elements:

• Date of service
  • Month
  • Day
  • Year
• Patient identifier
  • Name
  • MRN#
  • Patient ID
• Place of service
  • Home
  • School
  • Clinic
• Time
  • Time must be documented to support the units billed. With the exception of 97151 (which includes assessments and reassessments that require extensive non-face-to-face time to score assessments, review records and data, and write or update the treatment plan) the billed time must be spent face-to-face with the client. Time spent outside of face-to-face client therapy, such as time spent documenting, updating, reviewing, etc., cannot be included in the units billed for 97152-97158.
  • Documentation of time must include start and stop times.
  • Documentation of the RBT and BCBA/QHP start and stop times should be clearly and separately documented on each piece of documentation for the date of service.
• Narrative of session notes, which can include:
  • client behaviors with measured outcomes,
  • any redirection utilized,
  • goals/targets, and
  • modifications to therapy, if necessary.
• Diagnosis
• Assessment

The nature of behavioral health demands caution in exposing an individual’s personal and sensitive condition or situation. Therefore, most session notes do not include an overtly stated diagnosis. However, documentation best practice is to include the diagnosis on each separate session note. See below for a list of common acronyms associated with ASD.

Stay Current

While ABA therapy as a therapeutic invention for ASD and other developmental disorders has been around for decades, the AMA only issued CPT® codes for these services in 2019, making them relatively new codes. The issuing of permanent CPT® codes goes a long way in standardization, but there is still disparity among payers with the use of CPT® and HCPCS Level II codes, modifier use, and billing guidelines. To stay current, review payer guidelines on coverage conditions routinely and evaluate your documentation templates to ensure the required elements are present to establish medical necessity and meet coverage guidelines.

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Authors:

Carrie Severson, BSN, CPC, CPMA, COC, CPC-I, is regional director of AAPC Services. She has 10 years’ experience in the auditing arena and is highly skilled in auditing multiple specialties such as vision, family practice, pediatrics, internal medicine, and others. She is a subject matter expert in ophthalmology/optometry including eye services, procedures, and supplies. She is also a subject matter expert in behavioral health auditing including E/M, medication management, psychotherapy, Ketamine infusions, neuropsychological testing evaluation, and transcranial magnetic stimulation therapy. She was a clinical editor for educational products and examinations and has developed AAPC curriculum for several programs. Severson is an approved AAPC Professional Medical Coding Curriculum instructor and has 10 years’ experience with the AAPC Independent Study Program and online Distance Learning courses. She also received her Bachelor of Science in Nursing from Westminster College, Salt Lake City.

Jessica Whitney, CPC, CPMA, began her career in healthcare 25 years ago at Blue Cross of Idaho working in both provider relations and claims. She transitioned to practice management for both small, privately owned and large, multispecialty hospital-owned practices. She has spent over 20 years refining her expertise in practice management with a strong focus in coding and revenue cycle management for practices of all sizes. Whitney has in-depth knowledge of the credentialing and contracting process, as well as experience in reimbursement analysis and is a national speaker and author with experience in primary care, telehealth services, pain management, OMM, and podiatry. In her current role as director of RCM and Client Engagement with AAPC Services, Whitney manages the revenue cycle line of business as well as audits for a variety of specialties and is a training team member routinely participating in both coder and provider education.

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Resources:

CDC. Data & Statistics on Autism Spectrum Disorder.

Autism Speaks. What is Applied Behavior Analysis?
https://www.autismspeaks.org/applied-behavior-analysis.

ABAI, et call. Supplemental Guidance on Interpreting and
Applying the 2019 CPT Codes for Adaptive Behavior Services. Jan. 2019.
https://www.abainternational.org/ABAIUploads/Practice/FINAL_CPT® _Supplemental_Guidance_1_9_19.pdf.

https://autismsocietyoregon.org/glossary-of-commonly-used-terms-and-acronyms.

AAPC Codify

AMA CPT® 2022 Professional Edition