Autism Care Demonstration: Billing

Adaptive Behavior Services Current Procedural Terminology Codes

TRICARE-approved adaptive behavior services (ABS) Current Procedural Terminology (CPT^®) codes are specifically authorized and reimbursed under the Autism Care Demonstration (ACD) as approved by Health Net Federal Services, LLC (HNFS) during the clinical necessity review for the dates prescribed. ABS CPT codes are for use by applied behavior analysis (ABA) providers only. Please review TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.6.

SOLE OR TIERED DELIVERY MODEL

Sole: Board Certified Behavior Analyst^® (BCBA^®) or BCBA – Doctoral^® (BCBA-D^®) delivering direct 1:1 services.

Tiered: Assistant behavior analysts and behavior technicians (BT) delivering direct 1:1 services.

Treatment plans must specify whether CPT code 97153 will be delivered under the sole or tiered model, the location of services (for example, home, clinic), and the recommended and requested total number of units for each CPT code listed.

Code Descriptions

97151 – Behavior Identification Assessment

May be rendered by authorized ABA supervisors (or delegated to assistant behavior analysts).
Initial assessments are approved for 32 units per authorization period.
Reassessments approved for 24 units per authorization period.
Approved units include the administration, scoring and analysis of PDDBI.
Must be used within 14 calendar days of the first date of service.
No telehealth.

97151 – Outcome Measures

Units may be authorized under CPT code 97151 by HNFS for each additional outcome measure (Vineland Adaptive Behavior Scales, Third Edition [Vineland-3]; Social Responsiveness Scale, Second Edition [SRS-2]; Parenting Stress Index, Fourth Edition Short Form [PSI-4-SF]; Stress Index for Parents of Adolescents [SIPA]) rendered by the authorized ABA supervisor (not delegated to the assistant).
HNFS will issue a separate authorization for these outcome measures with one unit per measure authorized.
For these outcome measure units, include modifier 99 on the claim form.

97153 – Adaptive Behavior Treatment by Protocol

Rendered by authorized ABA supervisors (or delegated to assistant behavior analyst) and BTs.
- School setting:
  - Rendered by authorized ABA supervisors only.
    - Must be approved through the clinical necessity review process.
    - Services are focused, time-limited, and in accordance with the requirements of the ACD.
May not exceed 32 units per day or 160 units per week.
15 minutes per unit.
No telehealth.

97155 – Adaptive Behavior Treatment by Protocol Modification

Rendered by authorized ABA supervisors (or delegated to assistant behavior analyst).
At least one session per month must be rendered by the authorized ABA supervisor and cannot be delegated to an assistant behavior analyst.
- Providers are subject to a 10% penalty on all ABA claims for a beneficiary’s entire six-month authorization if not met.
- Ten percent penalty may be waived if no direct services were rendered within the calendar month.
Team meetings and Individualized Education Program (IEP) meetings excluded.
May not exceed eight units per day.
Fifteen minutes per unit.
No telehealth.

97156 – Family Adaptive Behavior Treatment Guidance

Rendered by authorized ABA supervisor (or delegated to assistant behavior analyst).
May not exceed eight units per day.
Fifteen minutes per unit.
ABA providers must render the first session of parent/caregiver training (CPT codes 97156 or 97157) within 30 calendar days of each treatment authorization.
Six parent/caregiver sessions every six months (CPT codes 97156 and/or 97157).
After first six-month authorization period, may be rendered via telehealth if authorized. Specific criteria apply. See our ABA Service Locations page for details.

97157 – Multiple-Family Group Adaptive Behavior Treatment Guidance

Rendered by ABA supervisor (or delegated to assistant behavior analyst).
May not exceed six units per day and eight participants per group. May only be used in an office/clinic setting.
Fifteen minutes per unit.
ABA providers must render the first session of parent/caregiver training (CPT codes 97156 or 97157) within 30 calendar days of each treatment authorization.
Six parent/caregiver sessions every six months (CPT codes 97156 and/or 97157).
No telehealth.

97158 Group Adaptive Behavior Treatment by Protocol Modification

Rendered by ABA supervisor (or delegated to assistant behavior analyst).
May not exceed six units per day and eight participants per group.
Fifteen minutes per unit.
No telehealth.

99366 and 99368 – Medical Team Conference

As of June 1, 2023, rates for CPT codes 99366 and 99368 are available on the CMAC Procedure Pricing page of www.health.mil instead of the Applied Behavior Analysis Maximum Allowed Amounts page.

Each locality has a different Non-Physician, Non-Facility rate and is based on the most recent effective date on the CMAC Procedure Pricing page. ABA providers will need to look up each locality where they render services to find the correct rate for CPT codes 99366 and 99368.

Rendered by ABA supervisor
Minimum of three qualified health professionals from different specialties who have performed face-to-face evaluations or treatments with the beneficiary within the previous 60 calendar days. (See TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.6.2.7 for more information.)
CPT code 99366 is medical team conference with the beneficiary present; CPT code 99368 is without the beneficiary present.
Beneficiaries with an assigned Autism Services Navigator (ASN) (new beneficiaries as of Oct. 1, 2021) must have the ASN present for the duration of the medical team conference for ABA providers to be paid.
HNFS will authorize one unit of CPT codes 99366 and 99368 every six months for all treatment authorizations.
Face to face or telehealth permitted. See our ABA Service Locations page for details.

Service Locations

Please review definitions/guidelines for home, clinics/centers, daycares, school settings, community settings, telehealth, and indirect services on our ABA Service Locations page.

PARENT/CAREGIVER TRAINING

ABA providers are required to initiate parent/caregiver training (CPT codes 97156 or 97157) within 30 days of an approved treatment authorization and conduct a minimum of six parent/caregiver training sessions (CPT codes 97157, 97158) per authorization period.

GROUP SETTING

CPT codes 97157 and 97158 may be authorized for up to six units per day for use by the authorized ABA supervisor (ABA supervisors may delegate CPT code 97157 to assistant behavior analysts) with no more than eight beneficiaries or parents/caregivers (see respective codes) in a group setting. For CPT code 97158, authorized ABA supervisors must demonstrate in the treatment plan that the beneficiary has the prerequisite skills to learn in a group delivery format for ABA therapy.

PROGRAM SUPERVISION VS. MODIFICATION

Services under CPT code 97155 cover adaptive behavior treatment with protocol modification where the authorized ABA supervisor or assistant behavior analyst resolves one or more problems with the protocol (for example, evaluating progress, progressing programs, modeling modifications, probing skills). The oversight and supervision of BTs and assistant behavior analysts is required as clinically appropriate and in accordance with Behavior Analyst Certification Board, Inc.® (BACB®) guidelines and ethics but are not billable under the ACD. Claims submitted for supervision may be denied or recouped.

Program Modification. ABA supervisors are required to render a minimum of one visit per calendar month of CPT code 97155 (program modification) to each beneficiary.

WEEKLY UNITS

The weekly units authorized for CPT code 97153 cannot be rolled over to other weeks. The week is defined as Sunday to Saturday.

MONTHLY UNITS

The monthly units authorized for CPT codes 97155, 97156, 97157, and 91758 cannot be rolled over to other months. The first month begins the day services are authorized to start and ends on the last date of that month. Each month thereafter is based on the calendar month. For example, if the authorization starts Feb. 10, 2023, then the first month is Feb. 10-Feb. 28, 2023, and the second month is
March 1-March 31, 2023.

UNITS THAT COVER THE LENGTH OF THE AUTHORIZATION

Units authorized over the length of an authorization, such as for CPT codes 97151, 99366 and 99368, can be submitted during any month of the authorization period.

Note: CPT code 97151 units authorized for treatment reassessment are specifically for preparing the reassessment during the last 60 days of the authorization period and must be used within 14 calendar days of the first date of service.

MEDICALLY UNLIKELY EDITS

The Defense Health Agency (DHA) determines the maximum number of units allowed to be billed per day for each CPT code. Medically unlikely edits (MUE) are fixed, and claims will deny if they are exceeded.

ABA providers cannot request MUEs be exceeded prior to rendering care.
If an MUE is exceeded, you may request a claim review after your claim has processed (supporting medical documentation required).

Note: The American Medical Association (AMA) published additional Category I codes for ABS, which also include CPT codes 97152 and 97154. At this time, these codes and procedures are not approved under TRICARE’s ACD.

Claims Information/Billing Tips

Please note: Autism Corporate Services Providers (ACSP) and sole ABA providers are responsible for knowing claims billing requirements and guidelines.

TAXONOMY

All claims must include the Health Insurance Portability and Accountability Act (HIPAA) taxonomy designation for each provider type. These taxonomies include:

103K00000X – Behavior analyst for master’s level and above
106E00000X – Assistant behavior analyst
106S00000X – BT
Other appropriate HIPAA taxonomy based on license/certification

NATIONAL PROVIDER IDENTIFIER

All claims must include the rendering provider’s full name and National Provider Identifier (NPI) for processing.

Providers new to the network must have an NPI in place and included in their application submission. Providers can verify their NPI record by visiting https://npiregistry.cms.hhs.gov.

Tax Identification Number

For your ACD-related reimbursements to process correctly, the Tax Identification Number (TIN) listed in an ACD authorization must be current and match the TIN submitted on the associated claims. Incorrect or non-matching TINs require HNFS to rekey authorizations and can lead to denied claims and delayed reimbursement.

Non-Matching TINs

If HNFS authorizes ABA services under a group TIN, but the related claim lists a different group TIN, we will deny the claim for not having an associated authorization. Make sure to send HNFS any changes made to TINs as soon as possible. This will allow us time to authorize services under the new TIN (or update active authorizations before you submit respective claims). You can verify which TIN shows on current authorizations when using our “Authorization Status” tool (login required).

TIN Changes or Additions

ABA provider groups must submit a completed W-9 (www.irs.gov/forms-pubs/about-form-w-9) containing an updated TIN along with a letter on company letterhead to HNFS.

Fax: 1-844-224-0381
Email: ACDNetwork@hnfs.com

RENDERING PROVIDER

To ensure proper claims processing, list the rendering provider in Box 24 of the 1500 claim form. For all CPT codes, list the rendering provider (ABA supervisor, assistant behavior analyst or BT) as the rendering provider in Box 24.

Per TRICARE policy and AMA CPT code guidelines, assistant behavior analysts and BTs are not independent providers according to their certifications and cannot be listed as the billing provider or bill for any ABA services. Assistant behavior analysts and BTs receive compensation from their authorized ABA supervisors.

SESSION TIMES

Include the start and end time of the session for all CPT codes on claims. Please use military time format and include a space between start and stop times (HHMM HHMM). Claims billed without session times on each line and in military format will reject and need to be resubmitted. Note: For concurrent billing session time guidelines, refer to the “Concurrent Billing” section below.

Document the session start and end times in one of the following locations:

For an electronic data interchange (EDI) claim, put the session times in Loop 2400 for each individual line note.
For XpressClaims, put the session times in each individual line note.

UNIQUE LINES FOR SERVICES BILLED

TRICARE requires every session of ABA services be identified as its own unique line on claims submitted. (See TRICARE Operations Manual, Chapter 18, Section 4, paragraph 8.11.4.) When billing for multiple services rendered on the same day by the same rendering provider, you must separate out sessions, even if the CPT code is the same. Claims billed with multiple sessions on one line will reject and need to be resubmitted.

Incorrect: Line one indicates 8 units of CPT code 97153; the line note includes session times of 0800 0900 and 1300 1400.
Correct:
- Line one indicates 4 units of CPT code 97153; the line note includes a session time of 0800 0900.
- Line two indicates 4 units of CPT code 97153; the line note includes a session time of 1300 1400.

MODIFIERS

TRICARE requires the use of specific modifiers to indicate patient presence and/or remote sessions. Adding a note such as “patient not present” or “patient with Registered Behavior Technician® (RBT®)” does not meet this requirement. Use the following modifiers as applicable:

HR – Family/couple with client present
HS – Family/couple without client present
GT or 95 – Parent/caregiver remote sessions
99 – Use with 97151 to identify outcome measures (Vineland-3, SRS-2, PSI-4-SF/SIPA)

See below for concurrent billing guidelines.

PLACE OF SERVICE CODES

02 (Telehealth)
03 (School)
11 (Office/Clinic)
12 (Home)
99 (Other) – non-school daycare, community settings

Find additional information on location codes at CMS.gov and our ABA Service Settings/Locations page.

Concurrent Billing

Concurrent billing is excluded for all ABA codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. The correct rendering provider must be identified in Box 24J on the claim form. Medical documentation should clearly identify who was present during the session – including all providers, the beneficiary and parents/caregivers, when applicable – and the location. Claims for concurrent billing that do not include the session times (see above) and the presence or absence of the beneficiary will deny. Document the required information in one of the following locations:

For an EDI claim, the notes should be in Loop 2400 for each individual line note
For XpressClaims, the notes should be in the individual line note

Concurrent billing modifiers

HR – Family/couple with client present
HS – Family/couple without client present

CONCURRENT BILLING CPT CODES ALLOWED

CPT Codes	97151	97153	97155	97156	97157	97158
97151	N/A	N/A
97153	Yes	N/A
97155	No	No	N/A
97156	Yes	Yes	Yes	N/A
97157	Yes	Yes	Yes	No	N/A
97158	Yes	No	No	Yes	Yes	N/A

97153 and 97155: Concurrent billing is not permitted. Only one CPT code should be billed when concurrent care services are performed.

97153 and 97156: Concurrent billing is permitted if the BT, assistant behavior analyst or ABA supervisor is working with the beneficiary (CPT code 97153) and the ABA supervisor or a different ABA supervisor or assistant behavior analyst is conducting parent/caregiver training (CPT code 97156) and the beneficiary is not present.

97155 and 97156: Concurrent billing is permitted if the authorized ABA supervisor or assistant behavior analyst is working with the beneficiary (CPT code 97155) with or without the BT present and a different ABA supervisor or assistant behavior analyst is conducting parent/caregiver training (CPT code 97156), and the beneficiary is not present.

97151 and 91753 or 97156: Concurrent billing is permitted if the authorized ABA supervisor or assistant behavior analyst is completing an element of the assessment (for example, direct time, report writing) under CPT code 97151 and a different ABA supervisor, assistant behavior analyst, or BT is rendering CPT codes 97153 or 97156. The beneficiary can only be present for one code.

97157 and 97158: Concurrent billing is permitted if the authorized ABA supervisor has delegated CPT code 97157 to the assistant behavior analyst who is facilitating the parent/caregiver group while the authorized ABA supervisor renders CPT code 97158 with a group of beneficiaries.

Electronic Funds Transfer

All network and non-network ABA provider claims must be submitted electronically. HNFS is required to reimburse sole ABA providers and ACSPs for ACD services via electronic funds transfer (EFT). Visit our Claims Submission page for more information.

If you are a sole ABA provider or ACSP who has not yet signed up for EFT, visit our EFT/ERA page to get started. New enrollments can take up to 45 days to process once HNFS has received all information.

Reimbursement Rates

Reimbursement rates vary by geographic locality and are based on independent analyses of commercial and Centers for Medicare & Medicaid Services' ABA rates.

Visit DHA's Applied Behavior Analysis Maximum Allowed Amounts page to view current rates.

Balance billing reminder: ABA providers may not bill the beneficiary more than 100% of the rates posted at www.health.mil/rates. The balance billing guidelines defined in the TRICARE Reimbursement Manual (Chapter 3, Section 1, paragraph 4.0) do not apply.

Penalties: At least one direct session per month for CPT code 97155 must be rendered by an authorized ABA supervisor and cannot be delegated to an assistant behavior analyst. HNFS must perform post-claims payment reviews to confirm compliance. Non-compliance will result in a 10% penalty on all ABA claims for the entire six-month authorization for that beneficiary.

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