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Adaptive Behavior Services Medical Billing and Coding Guide for 2021

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“Adaptive behavior” refers to the behaviors acquired and performed to meet the standards across everyday activities that may occur at school, home, work, during recreational activities, and in community settings.

Adaptive behavior is indexed on chronological age starting from early development because as a society, we have different expectations of all members of our community as they age. What a person does at age five is not necessarily done at age twenty-five and so on.

According the American Medical Association CPT codebook, Adaptive behavior services address:

  • Deficient adaptive behaviors (e.g., impaired social, communication, or self-care skills)
  • Maladaptive behaviors (e.g., repetitive and stereotypic behaviors, behaviors that risk physical harm to the patient, others, and/or property)
  • Other impaired functioning secondary to deficient adaptive or maladaptive behaviors, including, but not limited to, instruction-following, verbal and nonverbal communication, imitation, play and leisure, social interactions, self-care, daily living, and personal safety.

(Read more on autism and challenging behaviors.)

In this adaptive behavior services medical billing and coding guide, we will explore the difference in adaptive behavior assessment and adaptive behavior treatment and how to navigate through the billing of these procedures. 

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Frequently Asked Questions

Which categories of CPT codes pertain to adaptive behavior?

Adaptive behavior services are spread out across two categories in the AMA CPT codebook: category I (medicine section) and category III (temporary codes for emerging technology). As of January 2021, there are 8 category-I CPT codes and 2 category-III CPT codes pertaining to adaptive behavior services.

Which codes are used in adaptive behavior assessment?

CPT code 97151 covers the analysis of pertinent past data including medical diagnosis. CPT code 97152 refers to procedures performed by a technician under the direction of a physician or other qualified healthcare professional. CPT code 0362T must be administered by a physician or other qualified healthcare professional who is on site, with the assistance of two or more technicians.

What is the difference between CPT codes 97152 and 0362T?

The primary difference between CPT code 97152 and 0362T is the number of technicians involved in patient care. Additionally, CPT 0362T deals with destructive behavior whereas CPT 97152 deals with deficient adaptive behavior.

CPT code 0362T is used for behavior identification supporting assessment administered by the physician or other qualified healthcare professional who is on site (but may not necessarily meet face to face with a patient) with the assistance of two or more technicians. A team is used for a patient who exhibits destructive behavior, and the assessment is completed in an environment customized to the patient’s behavior.

Which codes are used in adaptive behavior treatment?

CPT Codes used in adaptive behavior treatment (as opposed to assessment) include 97153, 97155, and 0373T. For group treatment, use CPT codes 97154 or 97158. For family treatment, use CPT codes 97156, 97157, or 97158.

What is applied behavior analysis and how does it pertain to adaptive behaviors?

Applied behavior analysis, or ABA, is a method used to promote and develop adaptive behaviors in patients on the autism spectrum. It is a type of therapy rooted in the science of psychology, specifically the part of psychology concerning human learning and behavior.

What are some common mistakes made in adaptive behavior services medical coding?

Common errors include insufficient documentation, incorrect insurance verification, improper code assignment, and upcoding or downcoding.

Where can I get help with medical billing and coding for my practice?

At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management. Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.

Adaptive Behavior Services Medical Billing and Coding Guide for 2021

Types of CPT Codes

Adaptive behavior services are spread out across two different categories in the AMA CPT codebook. The first part of the codes is located in category I, under the medicine section. The other codes are located in category III, under temporary codes for emerging technology.

All category-I CPT codes are permanent codes accepted by CMS and other third-party payers. Category-III codes are intended to be used for data collection to substantiate widespread usage. Once the sunset date is reached, the CPT code may either be moved to category I or remain as category III with a revised sunset date. As of January 2021, there are:

  • 8 Category-I CPT codes for adaptive behavior services
  • 2 Category-III CPT codes

Adaptive Behavior Assessment

Under the first area of adaptive behavior assessment, there are two CPT codes from category I and one code from category III.

  • Behavior identification assessment CPT code 97151 includes the analysis of pertinent past data (including medical diagnosis), a detailed behavioral history, patient observation, administration of standardized and/or non-standardized instruments and procedures, functional behavior assessment, functional analysis, and/or a guardian/caregiver interview to identify and describe deficient adaptive behaviors, maladaptive behaviors, and other impaired functioning secondary to deficient adaptive or maladaptive behaviors.
    • As stated in the CPT code, this assessment must be “administered by a physician or other qualified healthcare professional” and conducted by licensed supervisors. However, behavior identification supporting assessments may be designed by the licensed supervisor and implemented by a treatment therapist.
    • It is important to make sure that all credentials and certifications for the performing physicians at   your practice are up to date. Here at Neolytix, we offer medical credentialing services for eligible physicians. We’ll ease the burden of credentialing and help your practice stay updated at all times.
    • The maximum number of units that can be reported on a given day is 8, which represents two hours of service.
    • Appropriate diagnosis codes: ASH, head trauma, impaired social skills and communication, developmental disabilities like physical, learning, language, and much more.
  • Behavior identification supporting assessment CPT code 97152 is performed by a technician under the direction of a physician or other qualified healthcare professional. Similar to CPT code 95151, CPT 97152 includes the physician’s or other qualified health care professional’s interpretation of results and may include functional behavior assessment, functional analysis, and other structured observations and/or standardized and non-standardized instruments and procedures to determine levels of adaptive and maladaptive behavior.
  • Behavior identification supporting assessment CPT 0362T includes the following requirements:
    • It must be administered by a physician or other qualified healthcare professional who is on site. However, they are not required to meet face-to-face with the patient;
    • The assistance of two or more technicians;
    • A team to help with a patient with destructive behavior;
    • The assessment must be completed in an environment customized to the patient’s behavior.

The biggest difference between CPT code 97152 and 0362T is the number of technicians involved in patient care. Additionally, CPT 0362T deals with destructive behavior whereas CPT 97152 deals with deficient adaptive behavior. 

NOTE: Medical documentation is crucial in determining which CPT codes should be used. If your practice needs assistance in developing an EMR template, please reach out to Neolytix for a consultation. 

For more, consult the latest edition of the Adaptive Behavior Assessment System.

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Summary Chart: Adaptive Behavior Assessment

 

CPT

Description_______________________________

Time 

Notes____________________________________________

97151

Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare 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

Per 15 mins

Performed by a physician or other qualified healthcare professional.

  • Conducting a face-to-face observation of patient (patient must be present)
  • Obtaining a history of current and past behavioral functioning
  • Reviewing previous assessments and health records
  • Conducting interviews with guardian/caregiver to further identify and define deficient adaptive or maladaptive behaviors
  • Administering standardized and non-standardized tests (eg, Assessment of Basic Language and Learning Skills (ABLLS) 
  • Interpreting test results

97152

Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes

Per 15 mins

Performed by technician under the direction of a physician or other qualified healthcare professional.

  • Deficient adaptive behavior(s), maladaptive behavior(s), or other impaired functioning secondary to deficient adaptive or maladaptive behaviors
  • 1 technician

0362T

Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: 

  • administered by the physician or other qualified healthcare professional who is on site; 
  • with the assistance of two or more technicians; 
  • for a patient who exhibits destructive behavior; 
  • completed in an environment that is customized to the patient’s behavior.

Per 15 mins

  • Physician or other qualified healthcare professional required to be on site
  • 2 technicians
  • Destructive behavior(s)
psychologist playing blocks with little child with autism syndrome

Adaptive Behavior Treatment

As opposed to adaptive behavior assessment, which diagnoses a patient’s medical condition, adaptive behavior treatment encompasses services geared towards specific treatment targets and goals based on information the physician gathered during the assessment. CPT codes are ranged based on how the session is administered (one-on-one, group, family, etc.). Each medical record should state which sessions were performed one-on-one with the patient and which, if any, involved other participants. 

The central goal of adaptive behavior is to reduce repetitive and aberrant behavior and improve communication and social functioning.

Adaptive behavior tasks are often broken down into small, measurable units. Each skill is practiced repeatedly, in isolation, until the patient masters it. If additional assessments are required, the provider may choose to perform another adaptive behavior assessment.

Likewise, code selection depends on whether there was protocol modification by the technician and the number of technicians involved in patient care. If documentation does not specify the number of technicians or whether there was a protocol modification, treatment is assumed to have been an adaptive behavior treatment by protocol, administered by one technician under the direction of a physician or other qualified healthcare professional.

 

CPT

Description

Time

Treatment = describe services that address specific treatment targets and goals based on the results of the previous assessment; includes ongoing assessment and adjustment of treatment protocols, targets, and goals.

97153

Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes

per 15 mins

97155

Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes

per 15 mins

0373T

Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:  

  • administered by the physician or other qualified healthcare professional who is on site; 
  • with the assistance of two or more technicians; 
  • for a patient who exhibits destructive behavior; 
  • completed in an environment that is customized, to the patient’s behavior.

Per 15 mins

Group = face to face with multiple patients at the same time 

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

per 15 mins

97158

Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes

per 15 mins

Family = face to face with guardian(s)/caregiver(s)

97156

Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes

per 15 mins

97157

Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes

per 15 mins

97158

Group (2+ people) adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes

per 15 mins

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Applied Behavior Analysis (ABA)

Applied behavior analysis, or ABA, is a method used to promote and develop adaptive behaviors in patients. It is a type of therapy rooted in the science of psychology, specifically the part of psychology concerning human learning and behavior.

ABA seeks principally to understand how human behavior and learning are affected by the environment. Its chief goal is to apply our scientific understanding of how humans behave in real—not clinical or laboratory—settings in order to promote good behaviors while discouraging detrimental or dangerous behaviors.

ABA is often used to help people on the autism spectrum learn adaptive behaviors. ABA has been shown to provide the following benefits in patients on the autism spectrum:

  • Boost language and communication skills
  • Increase attention span, focus, memory
  • Increase social skills
  • Boost academic performance

The techniques of behavior analysis have been studied for several decades and have assisted many patients on the autism spectrum learn different adaptive behaviors. In fact, therapists have employed ABA to help children with autism and other related developmental disorders since the mid-1960s.

According to a 2007 clinical report from the American Academy of Pediatrics, ABA “has been well documented” to help children on the autism spectrum learn adaptive behaviors. “sustained gains in IQ, language, academic performance, and adaptive behavior.”

Be aware that ABA is not the only form of treatment for autism. Despite popular conceptions, ABA and autism therapy are different. The terms are not interchangeable.

child psychologist and kid with dyslexia playing with building blocks

Common Billing Mistakes for Adaptive Behavior Services

  • Insufficient Documentation: Many requirements that must be met for each of these codes. If the provider does not supply the necessary information, the encounter cannot be coded properly. At minimum, the medical record should include: 
    • Type of service (assessment of treatment);
    • Medical Necessity (patient diagnosis);
    • Time spent with patient;
    • Number of technicians;
    • Deficient adaptive behavior or destructive behavior.
  • Insurance Verification: Since not all insurance companies pay for category-III CPT codes, it is crucial to double-check patient eligibility and whether or not an authorization is required. By documenting this properly, the practice will reduce denials and increase timely payments for rendered services.
  • Coding/Billing: The back-end staff should be educated on how to properly assign these CPT codes and stay up to date on AMA CPT changes in the CPT codebook. Additionally, pay attention to the location at which the service was rendered. Not all services will be rendered under Place of Service Code 11: Office Setting. Always follow up on claims to avoid errors. 
  • Upcoding/Downcoding/MUE: As we all know, downcoding is just as bad as upcoding. Always review the medically unlikely edits (MUE) and read the medical documentation to ensure that everything performed is correctly translated into the correct CPT code. If multiple procedures are performed during the same visit, pay attending to NCCI edits and unbundling relationships. 

At Neolytix, our coders are certified and trained professionals who can properly assign CPT codes and analyze the medical documentation to ensure that everything is completed correctly.

Family on a therapy

Conclusion

As you can see, medical coding and billing for adaptive behavior services is very complex with codes scattered between category I and category III of the AMA CPT codebook.

For assistance with this process, please do not hesitate to reach out to us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management. 

Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.

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