We're practitioners, behavior scientists - not accountants or billers. This wasn't in my Master's course. I didn't study this in Cooper. When was I suppose to learn about billing?
If your experience working corporate settings as a BCBA was anything like mine, then you were likely kept in the dark about billing, coding, and authorizations. And sadly, there isn't much information out there to help you. I'm going to do my best to get you started and at least more comfortable with this dark side of the profession.
CPT Codes
You may be wondering, what are CPT codes? CPT stands for Current Procedural Terminology (CPT), and is a medical code that is used to report which ABA services you carry out.
In ABA, there are several to familiarize yourself with. I'm going to list each number and then a brief description as to what they are. The ABA Coding Coalition has an excellent website with tons of free resources to help guide you through this process.
Assessment Codes
97151 - Behavior identification assessment (conducted by a BCBA or other qualified healthcare provider) - Category 1
97152 - Behavior identification supporting assessment (conducted by a qualified technician - i.e. RBT) - Category 1
0362T - Behavior identification supporting assessment with 2 or more technicians - Category 3
Adaptive Behavior Treatment
97153 - Adaptive behavior treatment by protocol (typically conducted by a qualified technician or BCBA) - Category 1
97154 - Group adaptive behavior treatment by protocol (typically conducted by a qualified technician) - Category 1
97155 - Adaptive behavior treatment with protocol modification (conducted by a BCBA or other qualified healthcare provider) - Category 1
97156 - Family adaptive behavior treatment guidance (conducted by a BCBA or other qualified healthcare provider) - Category 1
97157 - Multiple family group adaptive behavior treatment guidance (conducted by a BCBA or other qualified healthcare provider) - Category 1
97158 - Group adaptive behavior treatment with protocol modification (conducted by a BCBA or other qualified healthcare provider) - Category 1
0373T - Adaptive behavior treatment with protocol modification with 2 or more technicians - Category 3.
I may actually be even more confused after reading these.
It's completely understandable if you're confused after reading through those codes. We're going to go through each one and give you a better understanding of how to use them.
97151 - Behavior Identification Assessment
Who administers it? A BCBA or other QHCP.
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). Most insurance companies will approve a flat 4 hours of assessment. You will typically need to provide medical necessity to get more.
Does it need to be face to face? No.
What services does this code include? It includes direct observation with the client or guardians, administering assessments (VBMAPP, ABLLS, AFLS, PEAK, etc.), discussing findings / recommendations, analyzing data, scoring or interpreting results, preparing report, and writing report.
Can this code be billed concurrently? Yes, with 97152 or with 97153.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (parent, BCBA) included each time there is a session. In addition, you will need to provide a report of your findings, typically including and FBA or FA. You will also need to provide goals that justify the number of hours / units that you intend on requesting following the assessment.
97152 - Behavior Identification Supporting Assessment
Who administers it? Registered line technicians approved by your payer (RBTs, RLTs, etc.)
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This code is typically not requested, as it is often not needed. Many insurance companies will require medical necessity for this code. You should request the number of units you need based on the number of hours you plan on using a technician during the assessment.
Does it need to be face to face? Yes.
What services does this code include? When a technician is directly assisting with an assessment with a client present, under the direction of a BCBA. Technicians could be assisting with data collection, behaviors, running treatment protocols, DTT / NET demands, etc.
Can this code be billed concurrently? Yes, with 97151.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (parent, BCBA) included each time there is a session.
97153 - Adaptive Behavior Treatment by Protocol
Who administers it? Registered line technicians approved by your payer (RBTs, RLTs, etc.) or BCBAs
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This is your direct treatment code. It's arguably the most important code. If you're doing a comprehensive treatment plan, you'll want to request between 20-40 hours per week, depending on what you client requires.
Does it need to be face to face? Yes.
What services does this code include? Direct 1:1 therapy between the client and the registered technician. This includes: DTT, NET activities, behavior modification protocols, task analyses, etc. All programming MUST be under the direction of a BCBA or other qualified health care professional.
Can this code be billed concurrently? Yes, with 97155 or 97151.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (parent, technicians). Every face to face occurrence in which 97153 is billed should have a data sheet with those core data. In addition, you will need goals with quantitative data prepared to justify using those units / hours. These data will need to be logged and graphed in case you are ever audited. You can, of course, use electronic data collection software as well.
97154 - Group Adaptive Behavior Treatment by Protocol
Who administers it? Registered line technicians approved by your payer (RBTs, RLTs, etc.)
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This is possibly the most worthless code because of what your payers' rates will be. Typically this code is 1/4 of the same rate as your 97153 code.
Does it need to be face to face? Yes.
What services does this code include? Group therapy with more than 2 clients but no more than 8 clients. This code is only useful if you have a group of more than 4 (from a business perspective). Uses for this code: social groups lead by a technician, circle time, lunch objectives, small groups, etc.
Can this code be billed concurrently? No.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (technicians). Every payer is different, but many payers do not want to see multiple clients on the same data collection sheet. It's possible that every single client in the group requires a personal data sheet. Whatever protocol being run needs to be explained in the note.
97155 - Adaptive Behavior Treatment
Who administers it? BCBA, BCaBA or other qualified healthcare provider.
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This is your "supervision" code, but be very careful using that word. Typically, you should be requesting at least 10% of the 97153 code for supervision per week (i.e. 30 hours of 97153 = 3 hours of 97155). Some payers will easily exceed that number, others will not. We typically request 4 hours for clients who come at least 30 hours - never had a denial.
Does it need to be face to face? Depends - it should be face to face, but can be done via telehealth for some insurances.
What services does this code include? This is your basic supervision code, with behavior treatment modifications bundled into it. The BCBA should be directly supervising a technician with a client and making adjustments & modifications to the current protocols or programming in place. They should be modeling changes, while providing simultaneous direction to the client.
Can this code be billed concurrently? Yes, with 97153.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (therapist, technicians). This is the most important documentation after 97153. You will need to provide narrative data explaining what protocols are being run and why this "supervision" session was necessary - were there any changes to the programming, did you have to alter the setting, change therapists, etc. Notes should be detailed to justify the service.
97156 - Family Adaptive Treatment
Who administers it? BCBA, BCaBA or other qualified healthcare provider.
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This is your "parent training" code. Some insurances may pressure you into including a large portion of parent centered care. There typically aren't limits on how many hours you can request, and many insurances will be happy to see you moving towards a parent driven model.
Does it need to be face to face? Depends - it should be face to face, but can be done via telehealth for some insurances.
What services does this code include? This is your basic parent training code. This can be done with a client present or just with the parent present. It includes reviewing relevant programming data, concerns, etc. so long as the discussion is behavior analytical in nature.
Can this code be billed concurrently? This code can be billed at the same time as any other code, but the times should be recorded.
97157 - This is the exact same code but for groups of families. Groups must be between 2-8 families.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (parent, BCBA). Give general notes about what was discussed during the meeting, did the parent have questions / concerns, was the client present, did the parent work with the client 1:1, etc.
97158 - Group Adaptive Behavior Treatment
Who administers it? BCBA, BCaBA or other qualified healthcare provider.
How many units? It's a category 1 code, so it is billed in 15 minute units (1 hour equals 4 units). This is your "group supervision" code. This is a unique code often used for social groups.
Does it need to be face to face? Yes.
What services does this code include? This is a group supervision code, basically used for groups of 2-8 clients with a BCBA leading the group in behavior protocol modification. Some providers use this code for social groups, while others will simultaneously supervise large groups of therapists / clients at the same time. This code is ambiguous on details.
Can this code be billed concurrently? No.
How is this code documented? Whoever is running the session should have some sort of datasheet with dates, times, locations, services, and signatures (BCBA). Documentation should be similar to 97154 - try to avoid putting multiple clients on the same data sheet. Documentation should include what goals are being presented and what changes are being made to the protocols in place.
Calculating those hours for a 6 month period can be daunting.
Check out the video posted above. We use a spreadsheet to help us with calculating how many units / hours we need across a six month period for our clients. We're now selling copies of this spreadsheet for $1. You can use it for as many clients as you need. The spreadsheet comes with instructions on how to use it, and it's very customizable and user friendly.
You may still have trouble knowing where to start when it comes to determining your clients units / hours.
First, determine if your client is a focused client or a comprehensive client. In previous posts, we've discussed the difference, but as a refresher check out this brief article published by the BACB.
Figure out the long term objectives you have for this client, hypothesize how long they will remain in your care, check with the family about scheduling conflicts & availability, understand your own clinical structure or staff availability if providing services in the home / school settings.
Determine how many direct, 1:1 hours per day that you can dedicate to this client (97153). Next determine how many days per week you can see him or her. Enter that information into the spreadsheet above (or your own spreadsheet).
Take 10% of the number of hours you determined for 97153. Decide if that is enough BCBA time to make meaningful changes to his or her program. Don't be afraid to over estimate. It's better to have too many hours than not enough. Whatever number you come up with per week, enter that in for your 97155 and multiple by 26 (number of weeks in an authorization period).
Do you intend on having any group periods? Determine if a BCBA or technician will be overseeing that group. How many hours per day? How many days per week?
Typically we stay with clients longer than 1 authorization period. Do not forget to request assessment hours (97151). You will need to reassess at some point. Ask for at least 4 hours. Sometimes requesting more than 4 hours will requires a phone call explaining medical necessity. Don't be afraid to ask.
If the client has behaviors that warrant using a technician or multiple technicians during the session, don't be afraid to request 97152.
Most plans "require" some sort of parent training protocols in place. Determine how many hours per week or month that you intend on seeing them. There typically aren't limits on this request, and many insurance companies will attempt to steer you to a parent centered model. It's a great idea to make that shift when you start to consider transitioning or discharging that client. You can recoup the missing 97155 (supervision) hours with parent training hours (97156) instead.
When you've determined how many units per month for each code, include that information in your treatment plan. Your next job is to create a treatment plan that defends the hours that you've requested, and you successfully prove medical necessity.