ACD Billing Tips: Session Times, Unique Lines, Modifiers, Place of Service

Friday, August 6, 2021

In response to recent changes to TRICARE’s Autism Care Demonstration (ACD), we updated our claims systems on Aug. 1, 2021, to allow for new guidance put in place. Please review these important billing tips to help you minimize rejected or denied claims when billing for applied behavior analysis (ABA) services. As a reminder, we offer detailed claims requirements on our ACD Billing page.

Session times

TRICARE requires providers specify the start and end time for each session of ABA services, for all CPT® codes billed. Please use military time format (HHMM). Claims billed without session times on each line and in military format will reject and need to be resubmitted.  

• For EDI claims, put the session times in Loop 2400 for each individual line. 
• For XpressClaims, put the session times in each individual line note. 

Unique lines when billing for multiple services on the same day

TRICARE requires every session of ABA services be identified as its own unique line on claims submitted. (See TRICARE Operations Manual, Chapter 11, Section 4, paragraph 8.11.4.) This means when billing for multiple services that occurred 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 97153; the line note includes session times of 0800–0900 and 1300–1400.
  
  
• Correct
  Line one indicates 4 units of CPT 97153; the line note includes a session time of 0800–0900.
  Line two indicates 4 units of CPT 97153; the line note includes a session time of 1300–1400. 

Proper use of modifiers

As of Aug. 1, 2021, 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 RBT” does not meet this requirement. TRICARE requires the following modifiers, as applicable:

• HR – Family/couple with client present
• HS – Family/couple without client present
• GT or 95 – Parent/caregiver remote sessions
• GT or 95 – Remote outcome measure administration

Telemedicine Place of Service (POS)

Per the direction of the Defense Health Agency, as of Aug. 1, the POS code on claims for approved telemedicine services can be 02 or the most appropriate code that allows for accurate billing. The GT or 95 modifier remains required.

Find additional information at www.tricare-west.com/go/ACD-provider and www.health.mil/autism.