Autism Care Demonstration: Non-Applied Behavior Analysis Providers Billing for Medical Team Conferences

Wednesday, April 6, 2022

TRICARE allows for medical team conferences (MTCs) to be billed using Current Procedural Terminology (CPT®) codes 99366 (beneficiary or parent present) and 99368 (beneficiary or parent not present), including providers attending MTCs for beneficiaries with a diagnosis of autism spectrum disorder, who are participating in the Autism Care Demonstration (ACD). To use these codes, a minimum of three TRICARE-authorized qualified health professionals (QHPs) from different specialties, who are also directly involved in treating (or having recently treated) the beneficiary must participate in the MTC. This requirement has led to questions from non-applied behavior analysis (ABA) providers about billing these codes. Please review these non-ABA provider-specific frequently asked questions about MTCs. Please note: ABA providers have different requirements for billing these CPT codes and should visit the ACD Billing page for more information. 

Do the non-ABA providers who participate in the MTC need a prior authorization?
No. If a non-ABA provider bills for CPT codes 99366 and 99368, they do not need a prior authorization.

Does the beneficiary need a referral?
No. A referral is not required.

What is an appropriate diagnosis code?
To prevent services from rejecting as part of a bundled service, when attending an MTC for a beneficiary participating in the ACD, it’s important to use their primary diagnosis code of F84.0 when billing for MTC participation.

Do non-ABA providers need to document MTCs, and will non-ABA providers be audited under the ACD?
While non-ABA providers are not subject to audits under the ACD, they are still subject to other TRICARE audits. Non-ABA providers must adhere to general medical documentation requirements as defined by the TRICARE Operations Manual and their HNFS provider participation agreements, as applicable.

Why was my claim rejected?
Claims for CPT codes 99366 and 99368 may be rejected or subject to recoupment if:

• An incorrect CPT code was billed. For example: CPT 99366 was used for an MTC where the beneficiary or parent was not present.
• More than one provider from the same specialty was present at an MTC and both billed for reimbursement. For example: Two speech therapists attended the same MTC, and they both billed for reimbursement.
• An incorrect diagnosis code was used and resulted in a rejected bundled service claim.
• Fewer than three QHPs from different specialties, who are also providing direct care to the beneficiary and have provided direct care within the previous 60 calendar days, were present for the MTC.
• Participant was not present for the entire MTC.

Where can I find additional information?
To learn more about billing and reimbursement, visit our ACD Billing page. To learn more about CPT codes 99366 and 99368, refer to TRICARE Operations Manual, Chapter 18, Section 4.