If a conflict arises between a Clinical Payment and Coding Policy and any plan
document under which a member is entitled to Covered Services, the plan
document will govern. If a conflict arises between a CPCP and any provider contract
pursuant to which a provider participates in and/or provides Covered Services to
eligible member(s) and/or plans, the provider contract will govern. “Plan documents”
include, but are not limited to, Certificates of Health Care Benefits, benefit booklets,
Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue
Shield of TX may use reasonable discretion interpreting and applying this policy to
services being delivered in a particular case. Blue Cross and Blue Shield of TX has
full and final discretionary authority for their interpretation and application to the
extent provided under any applicable plan documents.
Providers are responsible for submission of accurate documentation of services
performed. Providers are expected to submit claims for services rendered using
valid code combinations from Health Insurance Portability and Accountability Act
approved code sets. Claims should be coded appropriately according to industry
standard coding guidelines including, but not limited to: Uniform Billing Editor,
American Medical Association, Current Procedural Terminology, CPT® Assistant,
Healthcare Common Procedure Coding System, ICD-10 CM and PCS, National Drug
Codes, Diagnosis Related Group guidelines, Centers for Medicare and Medicaid
Services National Correct Coding Initiative Policy Manual, CCI table edits and other
CMS guidelines.
Claims are subject to the code edit protocols for services/procedures billed. Claim
submissions are subject to claim review including but not limited to, any terms of
benefit coverage, provider contract language, medical policies, clinical payment and
coding policies as well as coding software logic. Upon request, the provider is urged
to submit any additional documentation.
Applied Behavior Analysis
Policy Number: CPCP011
Version 1.0
Clinical Payment and Coding Policy Committee Approval Date: October 7, 2024
Plan Effective Date: February 1, 2025
1
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Description
This policy was created to serve as a general reference on the reimbursement for
covered Applied Behavior Analysis services. Health care providers are expected to
exercise independent medical judgment in providing care to patients. CMS Medically
Unlikely Edits-MUE indicate that direct services are typically requested for up to 40
hours per week. Claims should be coded appropriately per industry standard
coding guidelines.
Reimbursement Information
Guidelines (unless otherwise provided in the member’s benefit):
Consistent with plan medical policy PSY301.021 Applied Behavior Analysis (ABA) for
Autism Spectrum Disorder (ASD) Diagnosis, and applicable state mandates:
• ABA services are not reimbursable to providers if the services are not
provided by a Qualified Healthcare Professional-QHP who is certified by
the Behavior Analyst Certification Board-BACB as a Behavior Analyst
and/or licensed in their state as a Licensed Behavior Analyst or Licensed
Psychologist.
• Reimbursement to providers is not available for ABA services that are
provided for educational, vocational, respite or custodial purposes.
• Reimbursement for programs/services rendered in a non-conventional
setting, such as anything other than Place of Service/POS codes 10, 11,
and 12, even if performed by a licensed provider, should have
supporting documentation on file within the member records and made
available upon request.
• Documentation must include rationale and a description for any unusual
POS code in order to be considered for reimbursement.
• Treatment plans and/or evaluations (inclusive of time for administration,
scoring, interpretation, and report write up) that exceed eight hours (32
units of 97151) may not be eligible for reimbursement to the provider
per industry standard coding guidelines.
• Consistent with practitioner guidelines (CASP, 2014), parent education is
authorized per week for the authorization period (typically 26 weeks) for
a total of 26 hours. Requests greater than one hour per week should
include supporting clinical documentation.
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• Please refer to the most current release of the CMS MUE table for
guidance on the maximum units of service that a provider would report
under most circumstances for a single member on a single date of
service. Service units are also limited by specific authorization period.
• Documentation of any units billed beyond industry standard coding
guidelines should justify any additional units billed. CPT code 97151
cannot be reported concurrently with other codes.
• CPT Codes 0362T and 0373T involve assessment and direct treatment of
severe maladaptive behavior. Services associated with these codes
should have defined treatment protocols that are separate and distinct
from a patient’s other treatment protocols. Consistent with the American
Medical Association CPT Coding Committee (2022) services must be:
▪ Administered by the physician or other qualified healthcare
professional who is on site;
▪ With the assistance of two or more technicians;
▪ For a patient who exhibits destructive behavior;
▪ Completed in an environment that is customized to the
patient’s behavior.
Examples of customized, specialized, and high-intensity settings
include a means of separating from other patients, use of protective
gear, padded isolation rooms with observation windows and medical
protocols for monitoring patient during and after high intensity
episodes, an internal/external review board to examine adverse
incidents, access to mechanical/chemical restraint, and frequent
external review to determine if the patient needs a higher level of care
and whether this patient be safely treated in an outpatient setting.
Alternatively, this level of support may be provided utilizing different
funding in day treatment, or different procedural codes for intensive
outpatient day treatment or inpatient facilities, depending on the
behavior.
• CPT code 97156 (Family Adaptive Behavior Treatment Guidance) is
expressly for the QHP to meet face-to-face with the guardians/caregivers
of the patient (with or without the patient present). This code should be
reported when engaging in this activity rather than 97155, which is
reserved for supervisory activities related to the patient's care.
• CPT codes are face to face and with one patient unless otherwise
specified in the description. Billable supervision of a patient must be face
to face and involves only one technician.
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There is no CPT code for indirect (patient not present) supervision
activities or week-to-week treatment planning. (The only codes that allow
for the patient not present are assessment/reassessment report writing
CPT code 97151, and family adaptive behavior treatment guidance CPT
code 97156).
• Documentation is required to substantiate that services were rendered
include but are not limited to: (1) a parent or caregiver’s signature for
each rendered service that also includes the service/code provided,
rendering provider’s name/signature, certification and credentials, place
of service, the date of service, and the beginning/end times of the
service, (2) a written account, summary, or note of the service rendered,
and (3) data point(s) may be required immediately after the service
occurred and for the purposes of audit.
• Consistent with practitioner guidelines (CASP, 2014), case supervision
activities are comprised of both direct supervision (patient present) and
indirect supervision (patient not present). Direct supervision includes
direction of Registered Behavior Technicians, treatment
planning/monitoring fidelity of implementation, and protocol
modification. Whereas indirect supervision includes developing
treatment goals, summarizing and analyzing data, coordination of care
with other professionals, report progress towards treatment goals,
develop and oversee transition/discharge plan, and training and
directing staff on implementation of new/revised treatment protocols
(patient not present).
• The AMA codes for Adaptive Behavior Services indicate that the activities
associated with indirect supervision are bundled codes and are
otherwise considered a practice expense and are not eligible for
separate reimbursement. Although indirect supervision is a practice
expense, documentation in the treatment plan of this service occurring
is expected by the Plan even though it is not reimbursable by the Plan
(CASP 2020, pp. 31) recommends 20% of direct hours be spent in “Case
Supervision activities” [both indirect and direct supervision combined]
and 50% of this time be used for direct supervision. Direct supervision
may be authorized for coverage consistent with the member’s benefits
at a minimum of 1 hour per week when less than 10 hours of direct
services are authorized.
• Direct treatment by a QHP (CPT codes 97152, 97153 or 97154). If the
QHP “personally performs the technician activities, his or her time
engaged in these activities should be reported as technician time.” (AMA
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CPT Coding committee, 2022). Further, these codes must be billed by an
appropriately trained technician and are not eligible for reimbursement
when performed by a caregiver.
• CPT codes 97154 and 97158 refer to group interventions. Groups must
contain no fewer than 2 members and no more than 8 members. QHP
direction of the technician as they render 97154 would be captured as
code 97155. QHP rendering group treatment with protocol modification
would be captured as 97158.
• Use a single modifier (HM, HN, HO) to indicate the level of education,
training, and certification of the rendering provider when CPT code
97153 is submitted.
• The provider who renders treatment week to week to the member is
considered the ‘rendering provider’ and should bill for the services
provided. A provider who is not rendering protocol modification, parent
education, assessment or report writing services should not bill for
services that they did not personally provide. An unlicensed, non-
network-credentialed, or otherwise non-qualified provider cannot
provide services and bill through another person’s NPI number and
receive reimbursement from the Plan. Any services performed by a
supervisee and billed through a supervisor should follow any applicable
state laws, Board requirements, and/or CMS conventions for
documentation and billing within a formal supervisor-supervisee
relationship.
• All covered services provided for and billed for by the Plan’s members by
contracting provider shall be performed personally by the Contracting
Provider or under that provider’s direct and personal supervision and in
the provider’s presence, except as otherwise authorized and
communicated by the Plan. Direct personal supervision requires that a
Contracted Provider be in the immediate vicinity to perform or to
manage the procedure personally, if necessary. Session notes should
reflect both parties were present for the entire duration of the
encounter.
• There may be times when it is clinically indicated to provide co-
treatment with another distinct service, such as Speech Therapy or
Occupational Therapy. Such co-treat sessions is generally for the
purpose of addressing defined behavioral or skills deficits present and
should be documented in the treatment plan as such. Co-treat sessions
should be billed with the appropriate modifier.
5
Reporting units for timed codes: In order to be reimbursable, when multiple units
of therapies or modalities are provided, the 8-minute rule must be followed when
billing for these services. In order to be eligible for reimbursement, a provider
should not report a direct treatment service if only one attended modality or
therapeutic procedure is provided in a day and the procedure is performed for less
than 8 minutes.
• The time reported should be the time actually spent in the delivery of the
modality and/or therapeutic procedure. This means that pre- and post-
delivery services should not be counted in determining the treatment
time.
• The time that the patient spends not being treated, due to resting periods
or waiting for a piece of equipment to become available, is not
considered treatment time.
• All treatment time, including the beginning and ending time of the direct
treatment, must be recorded in the patient’s medical record, along with
the note describing the specific modality or procedure.
The following units of service billing guideline has been published by Medicare. It is
the standard when billing multiple units of service with timed procedures defined as
per each 15 minutes.
➢ unit: ≥ 8 minutes through 22 minutes
➢ units: ≥ 23 minutes through 37 minutes
➢ units: ≥ 38 minutes through 52 minutes
➢ units: ≥ 53 minutes through 67 minutes
➢ units: ≥ 68 minutes through 82 minutes
➢ units: ≥ 83 minutes through 97 minutes
➢ units: ≥ 98 minutes through 112 minutes
➢ units: ≥ 113 minutes through 127 minutes
If any 15-minute timed service that is performed for 7 minutes or less on the same
day as another 15-minute timed service that was also performed for 7 minutes or
less and the total time of the two is 8 minutes or greater, then bill one unit for the
service performed for the most minutes. The same logic is applied when three or
more different services are provided for 7 minutes or less.
Example, if a provider renders:
➢ 5 minutes of CPT code 97035 (ultrasound),
➢ 6 minutes of CPT code 97110 (therapeutic procedure), and
➢ 7 minutes of CPT code 97140 (manual therapy techniques)
6
The claim should be filed with 1 unit of CPT code 97140 since the total minutes of
direct treatment is 18 minutes. The patient’s medical record should document that
all three modalities and procedures were rendered and include the direct treatment
time for each.
If any direct patient contact timed service is performed on the same day as another
direct patient contact timed service, then the total units billed cannot exceed the
total treatment time for these services.
Example, if a provider renders:
➢ 8 minutes of CPT code 97530 (therapeutic activities),
➢ 8 minutes of CPT code 97110 (therapeutic procedure), and
➢ 8 minutes of CPT code 97140 (manual therapy techniques)
The claim should be filed with a total of 2 units since the total minutes of direct
treatment is 24 minutes. The patient’s medical record should document that all
three modalities and procedures were rendered and include the direct treatment
time for each.
The following is not an all-encompassing coding list. The inclusion of a code below
does not guarantee it is a covered service or eligible for reimbursement. Exclusions
may apply under benefit plans or other plan documents.
CPT Code Guideline
0362T BHV ID SUPRT ASSMT EA 15 MIN
0373T ADAPT BHV TX EA 15 MIN
97151 BHV ID ASSMT BY PHYS/QHP
97152 BHV ID SUPRT ASSMT BY 1 TECH
97153 ADAPTIVE BEHAVIOR TX BY TECH
97154 GRP ADAPT BHV TX BY TECH
97155 ADAPT BEHAVIOR TX PHYS/QHP
97156 FAM ADAPT BHV TX GDN PHY/QHP
97157 MULT FAM ADAPT BHV TX GDN
97158 GRP ADAPT BHV TX BY PHY/QHP
Additional Resources
Clinical Payment and Coding Policy
CPCP023 Modifier Reference Policy
CPCP033 Telemedicine and Telehealth/Virtual Health Care Services Policy
7
Medical Policy
PSY301.021 Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD)
Diagnosis
References
1. American Medical Association CPT Coding Committee (2024). 2024 CPT
Professional Codebook. Chicago, Il: American Medical Association Publishing
2. American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders, (5th Ed.). Arlington, VA: American Psychiatric Publishing.
3. Counsel of Autism Service Providers (2020). Applied Behavior Analysis Treatment
for Autism Spectrum Disorders: Guidelines for Healthcare Funders and
Managers. Littleton, CO: Author. Available at https://casproviders.org/asd-
guidelines
4. Centers for Medicare & Medicaid Services Medically Unlikely Edits table (effective
1/1/2019). Available at
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
(accessed 2018 April 11).
Policy Update History
Approval Date Description
04/30/2018 New policy
02/22/2019 Coding updates
03/06/2020 Annual Review, Disclaimer Update
11/25/2020 Removed Telemedicine verbiage
11/09/2021 Annual Review
5/23/2023 Annual Review
10/07/2024 Annual Review
