In recent years, Applied Behavior Analysis (ABA) services have come under increased scrutiny by federal and state agencies for questionable billing patterns. In June 2021, the Office of Inspector General (OIG) announced it will conduct an audit on Medicaid claims for these services. The audit will determine whether payments made by Medicaid for ABA services complied with federal and state requirements. Commercial and governmental payers (e.g., Medicare, Medicaid, Tricare, etc.), each maintain unique guidelines and/or requirements associated with the provision of ABA services. Drawing on practical experience in assisting organizations with ABA payer audits and serving as an Independent Review Organization (IRO) for organizations under Corporate Integrity Agreements (CIA) with the OIG, PYA has identified several criteria that are common across most payers and are important for organizations to consider when providing ABA services.
ABA Defined
ABA is a common treatment used to improve socially important behaviors in children with autism and developmental disorders. The treatment helps target challenging behaviors that may be hindering a child’s development in school, at home, or in other community settings. Organizations that provide ABA services are tasked with providing high-quality patient care, as well as navigating complex billing and documentation rules to which they must adhere for appropriate compliance and proper reimbursement.
CPT®[1] Code Assignment
ABA services are typically billed using a mix of Category I[2] and Category III[3] CPT codes describing “adaptive behavior services.” Organizations should invest in properly training providers and office personnel regarding the selection of the most appropriate CPT code based upon the service(s) provided.
For example, there are various codes available for the performance of an adaptive behavior assessment. The appropriate code should be selected based upon several criteria, including:
- The time it took to perform the assessment.
- Whether the code allows non-face-to-face time to count toward the total billable time.
- The provider type.
- Whether the assessment was performed under the direction of a physician or other qualified healthcare professional.
Calculation of Billable Units for Time-Based ABA Services
ABA therapy services are primarily billed using time-based CPT codes, for which one billable unit typically equates up to 15 minutes spent delivering the service. In cases where the time spent with the client does not fall into neat 15-minute increments, most payers use the “8-Minute Rule”[4] to calculate how many units should be paid for the time-based service.
The Centers for Medicare & Medicaid Services (CMS) states that under this guideline, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code provided on the same day, measured in 15-minute units, providers should bill a single 15-minute unit for treatment time greater than or equal to 8 minutes through, and including, 22 minutes.
- 0 – 7 minutes: minimum requirements not met to bill one unit of service
- 8 – 22 minutes: requirements met to bill one unit of service
Why is it important to educate providers on unit requirements? Overstating units creates an obvious audit and compliance risk, while billing fewer units than what is allowed based on the time spent with the client could result in leaving reimbursement dollars on the table.
Assigning the Correct Units for Multiple Providers
It is easy to get tripped up assigning units when multiple providers are involved in a client’s care. For example, if a Registered Behavior Technician (RBT) provides services to a client for four hours and one of those hours included Board-Certified Behavior Analyst (BCBA) observation and/or supervision, providers should make sure they are not “double-dipping” and counting the overlapping time twice.
- Incorrect: The RBT bills for four hours of service, and the BCBA bills for one hour of service, for a total of five hours.
- Correct: The RBT should bill for three hours of service, and the BCBA should bill for one hour of service, for a total of four hours.
Group vs. Individual Sessions
Group versus Individual Sessions must adhere to the insurance-approved care plan, which typically directs whether sessions can include multiple patients or just one. Billing codes should match the way services are actually performed. For example, a provider may report CPT 97153 (Adaptive behavior treatment by protocol administered by technician under the direction of a physician or other qualified healthcare professional, each 15 minutes) for sessions in which face-to-face treatment is provided with one client, with a 1:1 client-provider ratio.
A treatment session during which face-to-face services are provided to two or more clients may be reported using CPT 97154 (Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes). Providers should ensure that all therapy sessions are performed in a manner that is consistent with the client’s care plan and payer-specific coverage requirements. Additionally, it is important to identify and adhere to any payer-specific limitations regarding the number of participants per group and the number of units allowed per day.
Medical Record Documentation
Documentation requirements vary widely from payer to payer, and failure to supply just one piece of necessary information can lead to revenue loss in the event of a payer audit. Providers of ABA services should consider implementing a standardized group of documentation elements, including, but not limited to:
- The client’s diagnosis.
- The place of service (home, office, school, etc.) or a note indicating the visit was performed via telehealth.
- The client’s name and/or identification number on all pages of the medical record.
- All individuals present during each therapy/treatment session.
- For example: “The client [name] was in the living room with the Behavior Technician [name]; the BCBA [name] was in the kitchen with the parent, without the client present.”
- The full name, legal signature, and applicable licensure and/or certifications for all providers rendering the service.
Even when the above requirements are met, it is equally important to ensure that the CPT code billed is supported by documentation in the medical record for the date of service.
Individual providers and organizations should continually monitor payer policies for updates and changes that may impact documentation or coding practices. Organizations should conduct routine internal monitoring and auditing activities of documentation and coding and provide education and corrective action for providers who are found to be non-compliant with documentation and/or coding requirements.
PYA assists all types of healthcare organizations with creating, evaluating, and expanding compliance infrastructure, including coding, documentation, and billing compliance. Additionally, PYA often serves as an IRO for entities subject to a CIA, and/or helps entities prepare to meet CIA requirements. If you have questions about ABA services compliance, contact a PYA team member below at (800) 270-9629.
[1] Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) are registered trademarks of the American Medical Association.
[2] Codes used for reporting devices and drugs (including vaccines), services or procedures performed by physicians and other healthcare providers, services or procedures performed intended for clinical use, services or
procedures performed according to current medical practice, and services or procedures that meet CPT requirements.
[3] Temporary codes used for reporting emerging technology, including services or procedures recently performed on humans, clinical trials, etc.
[4] Medicare Claims Processing Manual, Change Request 7247.
