Billing Codes forApplied Behavior Analysis
In July 2020, we adopted new Current Procedural Terminology (CPT®) billing codes proposed by the American Medical Association for Applied Behavior Analysis (ABA) treatment. Below is a list of revised billing codes that Evernorth uses for autism services. It explains how the codes should be used, what provider type can provide the given service, and who can bill for the given service.
As of December 1, 2020, precertification is no longer required for assessment CPT codes 97151, 97152, or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a Board Certified Behavior Analyst and the customer’s policy covers ABA services. If you provide ABA services, you only need to submit claims for these assessment services and they will be evaluated for payment. Claim submissions are evaluated according to industry standards. Please note that authorization is required for 97151, 97152, or 0362T when requesting a network exception.
All of the ABA CPT codes are in 15-minute increments.
| CODE | HOW THE CODE SHOULD BE USED FOR EVERNORTH BEHAVIORAL HEALTH | WHO CAN PROVIDE THE SERVICE? | WHO CAN BILL FOR THE SERVICE? |
|---|---|---|---|
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. | BCBA-D®,BCBA®, or licensed mental health provider | BCBA-D®,BCBA®, or licensed mental health provider |
| 0362T | Exposure behavioral follow-up assessment, includes physician or other qualified provider direction with the assistance of one or more technicians. 0362T is reported based on a single technician's face-to-face time with the patient and not the combined time of multiple technicians. | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare provider with one patient. | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare provider (with or without the patient present). | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare provider (without the patient present). | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |
| 0373T | Exposure adaptive behavior treatment with protocol modification, requiring two or more technicians for severe maladaptive behavior(s). 0373T is reported based on a single technician's face-to-face time with the patient and not the combined time of multiple technicians. | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |
| 97152 | Observational behavioral follow-up assessment, includes physician or other qualified provider direction with interpretation and report, administered by one technician. | BCaBA, Technician | BCBA-D, BCBA, or licensed mental health provider |
| 97153 | Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient. | BCaBA, Technician | BCBA-D, BCBA, or licensed mental health provider |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients. | BCaBA, Technician | BCBA-D, BCBA, or licensed mental health provider |
| 97158 | Adaptive behavior treatment social skills group, administered by physician or other qualified healthcare provider, face-to-face with multiple patients. | BCBA-D, BCBA, or licensed mental health provider | BCBA-D, BCBA, or licensed mental health provider |