Reimbursem*nt Policy:
Applied Behavior Analysis (ABA) in the Treatment of Autism Spectrum Disorders (ASD) Reimbursem*nt
Effective Date:
September 11, 2024
Last Review Date:
July 25, 2024
Purpose:
To provide guidelines for billing ABA in the treatment of Autism Spectrum Disorder. This policy applies to participating and non-participating providers.
Scope:
Products included:
- NJ FamilyCare/Medicaid
- Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
Definitions:
Industry Standard Codes:
| Code | Description |
|---|---|
| 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 |
| 97152 | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes |
| H0032 | Mental health service plan development by non-physician |
Temporary Category III CPT Codes:
| Code | Description |
|---|---|
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on-site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on-site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. |
Policy:
Horizon NJ Health will only consider ABA services for reimbursem*nt when these services are submitted on claims that include a diagnosis code related to Autism Spectrum Disorder, ICD-10 code range F84.0-F84.9. (e.g. F84.0, Autistic disorder) as diagnosed by a Qualified Health Professional (QHP) such as a Pediatrician, Pediatric Neurologist, Advanced Practice Nurses (APNs), or a Child Psychiatrist or Psychologist with Autism Services within their scope of practice.
Horizon NJ Health will only consider ABA services for reimbursem*nt when submitted by a Board Certified Behavior Analyst (BCBA/BCBA-D).
ABA services must be provided in a manner consistent with, and documented based on, the guidelines of Horizon’s Uniform Medical Policy, Applied Behavior Analysis in the Treatment of Autism Spectrum Disorders (ASD).
All ABA codes require prior authorization for medical necessity review Billing of ABA codes in excess of what has been authorized as medically necessary will not be considered for reimbursem*nt. Application of the Horizon recommended daily limits will result in requiring medical necessity review for any service codes that are billed in excess frequency of what has been authorized. Any request without prior authorization will prompt a denial of claims and require medical necessity review upon receipt of medical records.
Horizon NJ Health will apply the maximum daily allowable units for ABA service codes listed in the table below.
| Code | Unit Measure | Horizon Daily Limit |
|---|---|---|
| 97151 | 15 minutes | 32 units |
| 97152 | 15 minutes | 16 units |
| 97153 | 15 minutes | 32 units |
| 97154 | 15 minutes | 18 units |
| 97155 | 15 minutes | 24 units |
| 97156 | 15 minutes | 16 units |
| 97157 | 15 minutes | 16 units |
| 97158 | 15 minutes | 16 units |
| 0362T | 15 minutes | 16 units |
| 0373T | 15 minutes | 32 units |
| H0032 | 15 minutes | 4 units |
Horizon’s Daily Limits are based on industry standards and are intended to prevent over-utilization. Any codes where a provider bills in excess of the authorized codes and attempts to bill the same ABA services under alternative codes will be denied and/or subject to medical necessity review.
The CPT codes listed above are the preferred codes to be used and recommended by the AMA when rendering ABA services and when medically necessary based on MCG Criteria for ABA services (Applied Behavioral Analysis, ORG: B-806-T (BHG), MCG 28th Edition).
Procedure:
Horizon NJ Health will deny ABA claims submitted for reimbursem*nt of ABA services without an Autism Spectrum Disorder related diagnosis code included on the claim.
Horizon NJ Health will deny ABA claims submitted lines for reimbursem*nt of ABA services billed by a specialty other than a Board Certified Behavior Analyst (BCBA/BCBA-D).
Horizon NJ Health will deny ABA claims for reimbursem*nt of ABA services for units that are not authorized as medically necessary or that exceed the daily maximum units as clinically authorized per medical necessity based on MCG.
Resources:
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
History:
07/25/2024: Policy approved.
017M_07252024
