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Applied Behavioral Analysis (ABA) Coding Policy
Applied Behavior Analysis (ABA) is defined as the application of techniques and principles to assess and improve socially important human behaviors which focuses on how learning takes place and positive reinforcement. The goal of this treatment is to improve communication, cognitive skills, social interaction, and adaptive behavior. Educational interventions include both the behavioral and habilitative strategies concentrating on the development of communication skills, socialization skills, adaptive skills, and control or ablation of disruptive behaviors.
Effective January 1, 2015, Applied Behavioral Analysis (ABA) is a covered service for treatment of Autism Spectrum Disorder (ASD) for Blue Cross & Blue Shield of Mississippi (BCBSMS) members.
The purpose of this policy is to define billing and reimbursement guidelines for Applied Behavioral Analysis services. Medically Necessary criteria and Prior Authorization requirements to support reimbursement of these services are defined in the Treatment of Autism Spectrum Disorder (ASD) Medical Policy and can be viewed at {{blue:(www.bcbsms.com}} or www.MyAccessBlue.com.
Indications and Limitations of Coverage
Applied Behavioral Analysis treatment is covered when services are rendered by a Board Certified Behavior Analyst with a current certification by the Behavioral Analyst Certification Board (BCBA or BCBA-D) or by a Board Certified Assistant Behavioral Analyst (BCaBA) and/or a Licensed Board Certified Registered Behavior Technician (RBT) that is supervised by a BCBA or BCBA-D provider. (See Policy Exceptions.) However, claims can only be filed by the BCBA or BCBA-D provider. Services rendered by the assistant (BCaBA) and/or technician (RBT) must be filed by the supervising BCBA or BCBA-D provider. The time of the assistant (BCaBA) and/or technician (RBT) is considered practice expense and is not reported separately. Additionally, if both the BCBA or BCBA-D and the BCaBA or RBT is present, time is based on a single technician's face to face time and not the combination time of both providers.
The following information provides the service codes and reporting limitations applied to each ABA code that is to be reported by the referred BCBA or BCBA-D Provider:
Applied Behavioral Analysis (ABA) identification assessment code which includes the treatment plan is covered no more than once every six (6) months.
CPT Code | 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 |
Follow-up ABA assessment codes are covered for a combined total of six (6) hours every six (6) months.
CPT Code | Code Description |
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 |
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. |
The following adaptive behavioral treatment codes are limited to the (medically necessary hours per week (7 days) (according to the Member's individualized specific treatment plan.
CPT Code | Code Description |
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 |
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 |
The following behavior treatments with protocol modification is covered for three (3) hours every two (2) months. Effective 9/16/19, 97155 for adaptive behavior treatment with protocol modification is covered two (2) hours for every ten (10) hours of therapy received.
CPT Code | Code Description |
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 |
The following behavior treatments with protocol modification is covered for three (3) hours every two (2) months.
CPT Code | Code Description |
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 |
If any of the reporting criteria is not met or the hours outlined above are exceeded, the services will be denied as not medically necessary and the member held harmless.
The following chart provides the appropriate coding and reporting guidelines for the time-based ABA codes for dates of services prior to 1/1/2019. For 1/1/2019 and after, all ABA codes are reported in 15 minutes increments. If the physician or other qualified health care professional personally performs the technician activities, his or her time engaged in these activities should be included as part of the required technician time to meet the components of the code. Regardless of the dates of services, codes should be selected based on the services being rendered.
Face-to-Face Technician Time | Codes Reported |
0360T-0369T | |
Less than 16 minutes | Not reportable |
16-45 minutes | 0360T, 0362T, 0364T, 0366T, 0368T |
46-75 minutes | 0360T and 0361T with 1 unit 0362T and 0363T with 1 unit 0364T and 0365T with 1 unit 0366T and 0367T with 1 unit 0368T and 0369T with 1 unit |
76-105 minutes | 0360T and 0361T with 2 units 0362T and 0363T with 2 units 0364T and 0365T with 2 units 0366T and 0367T with 2 units 0368T and 0369T with 2 units |
Each additional 30 minute increments | 0361T, 0363T, 0365T, 0367T, 0369T |
0373T-0374T | |
Less than 31 minutes | Not reportable |
31-75 minutes | 0373T |
76-105 minutes | 0373T and 0374T with 1 unit |
106-135 minutes | 0373T and 0374T with 2 units |
Each additional 30 minute increments | 0374T |
The charts below provide guidance on how to report the individual adaptive behavior services for dates of services 1/1/2019 and after.
Guide to Selection of Codes 97152 and 0362T (Individual Behavior Identification Supporting Assessment)
97152 | 0362T | |
Physician or other qualified health care professional required to be on-site Note: “On-site” is defined as immediately available and interruptible to provide assistance and direction throughout the performance of the procedures, however, the physician and other qualified health care professional does not need to be present in the room when the procedure is performed. | √ | |
Physician or other qualified health care professional not required to be on-site | √ | |
Number of technicians | 1 | 2 or more |
Deficient Adaptive behavior(s), maladaptive behavior(s), or other impaired functioning secondary to deficient adaptive or maladaptive behaviors | √ | |
Destructive behavior(s) | √ | |
May include functional analysis | √ | √ |
Environment customized to patient and behavior | √ |
Guide to Selection of Codes 97153, 97155, and 0373T (Individual Adaptive Behavior Treatment)
97153* | 97155* | 0373T | |
By Protocol | √ | ||
With protocol modification | √ | √ | |
Physician or other qualified health care professional face-to-face with patient | √ | ||
Physician or other qualified health care professional required to be on-site Note: “On-site” is defined as immediately available and interruptible to provide assistance and direction throughout the performance of the procedures, however, the physician and other qualified health care professional does not need to be present in the room when the procedure is performed. | √ | ||
Physician or other qualified health care professional required not to be on-site | √ | ||
Number of technicians | 1 | 1 | 2 or more |
Deficient Adaptive behavior(s), maladaptive behavior(s), or other impaired functioning secondary to deficient adaptive or maladaptive behaviors | √ | √ | |
Destructive behavior(s) | √ | √ | |
Environment customized to patient and behavior | √ |
*97155 may be reported concurrently with technician delivered services 97153 when the patient is present, one or more protocols have been identified and the qualified health professional is directing the technician.
This policy does not apply to the following:
Self-Funded Groups that exclude ABA services within their contract benefit plan.
Federal Employee Program (FEP) Members: Benefits are available for Standard Option, Basic Option, and Blue Focus Members. Only Standard Option Members may receive services from Non-Network Behavior Analyst Certification Board certified practitioners. For Blue Focus Members, benefits for ABA for treatment of ASD are limited to 200 hours per person, per calendar year.
The coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.
02/19/2015-Policy Drafted
06/29/2015-Removed State Health Plan from the Policy Exception. The State Health Plan is subject to policy effective 7/1/2015. Added State Health Plan contact information. Updated policy to clarify which codes are appropriate for ABA treatment and assessment and the level of supervision required.
01/15/2018-Age limitation of 8 years and under was removed.
12/28/18-Added new 2019 ABA CPT Codes and Guidelines.
8/19/19- Revised for Licensed Board Certified Registered Behavior Technician (RBT) criteria.
9/16/19- Revised criteria for behavior treatments with protocol modification.
12/3/20-Policy reviewed. Removed deleted/revised codes and code description from the tables that were under the 'Prior to 2019' column heading: 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T, 0367T, 0370T, 0371T, 0372T, 0368T. 0369T, 0373T and 0374T and coding information from the tables and deleted the '2019' row heading from the tables.
08/01/2024: Policy updated to remove Prior Authorization requirements from the Coding Policy as current requirements are outlined in the Medical Policy. Deleted Federal Employee Program (FEP) from the Policy Exceptions.
10/15/2025: Removed the maximum of 25 hours a week for ABA treatment codes 97153, 97154, 97156, 97157, and 97158. Updated to state these adaptive behavioral treatment codes are limited to the medically necessary hours per week (7 days) according to the Member's individualized specific treatment plan. Policy Exceptions updated regarding FEP members.
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2019 CPT Professional Edition Manual
Adaptive Behavior Assessment and Treatment Code Conversion Table https://www.bacb.com/wp-content/uploads/CPT_Codes_Crosswalk_.pdf