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  • More CPT Code Information – New Codes Active Jan 2019

    Posted on September 5, 2018 by in Policy, Private Practice, State Resources

    Note, a revision was sent out in mid October:

    In September the Steering Committee for the national workgroup comprising representatives of the organizations shown above distributed a code conversion table showing the most common HCPCS and 2014 Category III CPT codes that have been used to report applied behavior analysis (ABA) services to health plans, cross-referenced to the 8 new Category I and 2 modified Category III CPT codes that will go into effect January 1, 2019. Based on questions and feedback from many providers and payors, we have revised the code conversion table to clarify several points of confusion. Changes are as follows:

    • The date of the revision is shown in the upper right corner of the table.
    • The footnote defining QHP has been revised to be consistent with the American Medical Association and Centers for Medicare & Medicaid Services (CMS) definition of Qualified Healthcare Professional: “A ‘physician or other qualified healthcare professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” Note that decisions as to who can serve as a QHP for reporting the new CPT codes will be based on each state’s licensure laws (where applicable) and/or health insurance laws and regulations.
    • A note has been added (page 1, lower right corner) to indicate that new CPT codes 97153 (adaptive behavior treatment by protocol administered by technician) and 97155 (adaptive behavior treatment with protocol modification administered by QHP, which may include simultaneous direction of technician) may be reported concurrently as long as the requirements encompassed in the descriptors for both codes are met and the providers performing the services are not the same individuals.

    We would also like to take this opportunity to remind providers how important it is to obtain complete and accurate information about the new CPT codes. Although we certainly hope the code conversion table will be helpful, it is essential that you obtain and digest additional resources to ensure compliance with AMA coding and reimbursement rules and guidelines. Those resources include the 2019 CPT code book and the forthcoming CPT Assistant article, which will be published later this fall. They can be purchased from the AMA store, https://commerce.ama-assn.org/store/.  Our Steering Committee is also preparing materials to help providers and payors implement the new codes. One of those resources is this set of suggestions to help providers prepare for implementation of the new codes, including communicating with payors. Watch for emails announcing the availability of additional resources.

    If you have comments or questions or need additional information, please contact our CPT coding consultant Jenna Minton, Esq. at mintonhealthcarestrategies@gmail.com.

    Sincerely,
    Travis Thompson, Association for Behavior Analysis International
    Gina Green, Association of Professional Behavior Analysts
    James E. Carr, Behavior Analyst Certification Board
    Lorri Unumb, Autism Speaks
    Jenna W. Minton, Minton Healthcare Strategies (CPT Consultant)

     

     

    Original communication from APBA:

    As you may know, the American Medical Association (AMA) has approved eight new Category I and two revised Category III CPT® codes to report applied behavior analysis (ABA) services (termed “adaptive behavior assessment and treatment services”) to health insurance plans. Those codes take effect January 1, 2019. The new codes resulted from a code change application submitted to the AMA CPT Editorial Panel in 2017 by the Steering Committee for a national workgroup comprising representatives of the Association for Behavior Analysis International (ABAI), Association of Professional Behavior Analysts (APBA), Autism Speaks, Behavior Analyst Certification Board (BACB), CPT consultants, providers, and representatives of some health plans. In preparing the code change application, the Steering Committee collected extensive information about utilization of the Category III CPT code set that has been used for reporting ABA services since 2014. We also sought input from other stakeholder societies.

    To help payers and providers achieve consistency in utilization and implementation of the new codes, we have prepared a coding conversion crosswalk, available here and in the Members Only section of the APBA website under Health Insurance. It indicates the most common HCPCS and 2014 Category III CPT codes that have been or are being used by payers to report ABA services, and cross references those older codes to the 2019 Category I and III CPT codes. The crosswalk is organized by the essential elements of ABA services: assessment and reassessment, treatment plan development and revision, direct treatment of individual clients, direction of technicians by a professional behavior analyst or other qualified healthcare professional (QHP), family or caregiver training, and group treatment. For each new code, the crosswalk also indicates which personnel must attend each service in order to bill for that service as well as applicable time increments.

    We hope this information will foster an understanding of how the 2019 CPT codes are intended to be reported and encourage uniform reporting of ABA services across providers, payers, and states. If you have comments or questions or need additional information, please contact our CPT coding consultant JennaMinton, Esq. at mintonhealthcarestrategies@gmail.com.

    Sincerely,

    Travis Thompson, Association for Behavior Analysis International
    Gina Green, Association of Professional Behavior Analysts
    James E. Carr, Behavior Analyst Certification Board
    Lorri Unumb, Autism Speaks
    Jenna W. Minton, Minton Healthcare Strategies (CPT Consultant)

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