Adaptive Behavior Services Medical Billing and Coding Guide for 2024

Looking for help on adaptive behavior services medical billing and coding? Neolytix presents this comprehensive 101-guide for best coding practices for 2021.

Adaptive behavior services address a range of deficient and maladaptive behaviors, including impaired social skills, communication, and self-care. These services also encompass repetitive and stereotypic behaviors that may pose risks to the patient, others, or property. The goal is to improve adaptive behaviors such as instruction-following, communication (both verbal and nonverbal), imitation, play, social interactions, self-care, daily living, and personal safety. 

Adaptive behavior is measured according to chronological age, beginning from early development stages. This is because societal expectations change as individuals grow older. For instance, behaviors appropriate for a five-year-old are not necessarily suitable for a twenty-five-year-old. This age-specific approach helps tailor interventions effectively to meet developmental milestones and societal norms. 

Core Components of Adaptive Behavior Services 

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

  • Functional behavior assessment comprises descriptive procedures designed to identify environmental events that occur just before and just occurrences of potential target behaviors, which may influence those behaviors. 
  • Functional analysis is an assessment procedure for evaluating the effects of each of several environmental events on a potential target behavior by systematically presenting and withdrawing each event to a patient multiple times and observing and measuring occurrences of the behavior in response to those events. 
  • Standardized instruments and procedures include, but are not limited to, behavior checklists, rating scales, and adaptive skill assessment instruments that comprise a fixed number of items and are administered and scored uniformly with all patients (e.g., Pervasive Developmental Disabilities Behavior Inventory, Brigance Inventory of Early Development, Vineland Adaptive Behavior Scales). 
  • No standardized instruments and procedures include but are not limited to, curriculum-referenced assessments, stimulus preference assessment procedures, and other procedures for assessing behaviors and associated environmental events specific to the individual patient and behaviors. 

(Read more on autism and challenging behaviors.) 

The “Adaptive Behavior Services Medical Billing and Coding Guide for 2024” will explore key differences between adaptive behavior assessment and adaptive behavior treatment, as well as some key concepts and comparisons. In this context, We will also explore how to navigate through the billing of these procedures. 

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Key Concepts and Comparisons

Applied Behavior Analysis vs Occupational Therapy: While both ABA and occupational therapy aim to improve daily functioning, ABA therapy focuses on modifying behavior through reinforcement techniques, making it particularly effective for children with autism. Applied behavior analysis occupational therapy integrates principles of both fields to address adaptive behaviors in various contexts. 

Cognitive Behavioral Therapy vs. Applied Behavior Analysis: Cognitive Behavioral Therapy (CBT) and Applied Behavior Analysis (ABA) are often compared due to their behavioral focus. However, cognitive behavioral therapy vs applied behavior analysis reveals that CBT primarily targets thought patterns to influence behavior, while ABA uses reinforcement strategies to shape behavior directly. 

What is Applied Behavior Analysis Therapy?  

Applied Behavior Analysis ABA therapy is a structured approach used to teach and reinforce positive behaviors in individuals, particularly those with developmental disorders such as autism. It involves breaking down skills into small, manageable steps and systematically reinforcing each step. It plays a vital role in improving communication, social skills, and daily living activities. 

By comparing cognitive behavioral therapy vs. applied behavior analysis, and understanding the specific ABA therapy codes, we can better appreciate the unique contributions each approach makes to the field of behavioral therapy. 

CPT Codes 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 2024, there are 8 category-I CPT codes and 2 category-III CPT codes pertaining to adaptive behavior services. This categorization helps in streamlining the Behavior Services Medical Billing process and ensuring accurate billing practices. 

Which Codes Are Used For 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. 

Are These Codes Approved For Telehealth Services?

As of January 1, 2024, CMS has finalized the therapeutic service of telehealth Category 3 codes, which includes adaptive behavior/ABA services codes (97151-97158, 0362T, 0373T). However, audio-only interactions do not meet telehealth requirements, emphasizing the need for video and interactive sessions for services for ABA therapy billing. 

What Is The Difference Between Cpt CodeDs 97152 And 0362t?

The primary difference between CPT code 97152 and 0362T is the number of technicians involved and the nature of the behavior being addressed.  

CPT 0362T deals with destructive behavior that requires a team of technicians and involves higher risks, whereas CPT 97152 addresses deficient adaptive behavior. Additionally, the 97152 CPT code is often compared in discussions of occupational therapy vs applied behavior analysis. 

Similarly, CPT code 0362T is used for behavior identification supporting assessment and adaptive behavior treatment with protocol modification (0373T), include the following required components:  

  • 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.  
  • for a patient with destructive behavior that requires the presence of a team.  
  • completion in an environment that is 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 or 97157. These codes cover various adaptive behavior treatment types, ensuring comprehensive billing practices. 

What Is Applied Behavior Analysis (ABA) and How Does It Pertain to Adaptive Behaviors?

Applied Behavior Analysis (ABA) therapy is a type of therapy frequently applied to children with autism and other developmental disorders. It focuses on imparting skills in specific domains of functioning, such as social skills, communication, academic and learning skills, motor dexterity, hygiene, and grooming. The comparison of applied behavior analysis vs cognitive behavioral therapy highlights the structured and data-driven approach of ABA. 

What Are Some Common Mistakes Made In Adaptive Behavior Services Medical Coding?

Common errors in Behavior Services Medical Billing include insufficient documentation, incorrect insurance verification, improper code assignment, and upcoding or downcoding. Utilizing proper billing practices and services for ABA therapy billing can help mitigate these errors. 

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: Category I (permanent codes) and Category III (temporary codes for emerging technology). 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.  

These codes are essential for autism physician billing and ensuring compliance with CMS and other third-party payers. As of January 2024, 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 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 
  • 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 will ease the burden of credentialing and help your practice stay updated. 
    • 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, face-to-face with the patient, each 15 minutes. 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: 
    • administered by a physician or other qualified healthcare professional who is on site but not necessarily face-to-face with the patient. 
    • with the assistance of two or more technicians. 
    • for a patient with destructive behavior that requires the presence of a team. 
    • completion in an environment that is 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 and Treatment Code Conversion Table

CPT Code
Description
Time
Notes
Telehealth Approved

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

Per 15 mins

Performed by a physician or other qualified healthcare professional.

  • Conducting a face-to-face observation of the 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

Yes

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

Yes

0362T

Behavior identification supporting assessment, each 15 minutes of technician’s time face-to-face with a patient

Per 15 mins

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

  • Physician or other qualified healthcare professional required to be on site

  • 2 technicians

  • Destructive behavior(s)

Yes

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 master’s 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.

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.
CPT Code
Description
Time
Telehealth Approved

97153

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

Per 15 mins

Yes

97155

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

Per 15 mins

Yes

0373T

Adaptive behavior treatment with protocol modification, each 15 minutes of technician’s time face-to-face with a patient

Per 15 mins

Yes

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

97154

Group adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes

Per 15 mins

Yes

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

Per 15 mins

Yes

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

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

Per 15 mins

Yes

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

Per 15 mins

Yes

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

Yes

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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, particularly those on the autism spectrum. Rooted in the science of psychology, specifically the study of human learning and behavior, ABA seeks to understand how the environment influences behavior.  

By applying this understanding in real-world settings, ABA aims to encourage positive behaviors and discourage detrimental or dangerous ones. 

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, conceptions, applied behavioral analysis therapy 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

Proper billing and coding are crucial for the effective management of adaptive behavior services. However, common mistakes can lead to claim denials and reduced payments. Here are some key areas to watch for: 

  • Insufficient Documentation: Each code requires specific information to be documented. 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 authorization is required. Proper documentation of this can help reduce denials and ensure timely payments. 
  • 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 is performed and correctly translated into the correct CPT code. If multiple procedures are performed during the same visit, pay attending to NCCI edits and unbundling relationships. 
Family on a therapy

Unlocking Potential through Effective ABA Therapy Coding

As you can see, medical coding and billing for adaptive behavior services is overly 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 services. 

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. 

Frequently Ask Questions

Adaptive behavior treatment focuses on addressing deficient adaptive behaviors such as impaired social skills, communication, and self-care. It includes services aimed at reducing maladaptive behaviors and improving overall functioning. Adaptive behavior treatment procedures are designed to enhance the patient’s daily living and personal safety skills. 

Billing insurance as a BCBA involves understanding the specific CPT codes applicable to the services provided. Utilizing aba therapy billing services ensures accurate billing and coding, reducing claim denials and optimizing revenue. Autism billing services can assist in navigating complex insurance requirements. 

Applied behavior analysis (ABA) therapy is a treatment often used for children with autism and other developmental disorders. It focuses on improving specific skills such as social, communication, academic, and motor skills. Applied behavior analysis therapy for autism has shown significant benefits in enhancing various adaptive behaviors. 

CPT code 97152 refers to behavior identification supporting assessment, conducted face-to-face by a technician under the direction of a physician or qualified healthcare professional. This code is crucial for identifying and assessing deficient adaptive behaviors. Understanding the 97152 CPT code description helps ensure accurate billing. 

While adaptive behavior treatment and applied behavior analysis ABA therapy overlap, they are not identical. ABA is a broader approach focusing on behavior modification across various domains, while adaptive behavior treatment specifically targets improving daily living and safety skills. 

Group adaptive behavior treatment involves multiple patients receiving therapy simultaneously, guided by a technician or healthcare professional. Group adaptive behavior treatment codes like 97154 and 97158 are used for billing these services, which aim to improve social interactions and adaptive skills in a group setting. 

Yes, a BCBA can bill CPT code 97153, which covers adaptive behavior treatment by protocol administered face-to-face by a technician under the supervision of a qualified professional. This code is essential for billing applied behavior analysis therapy sessions. 

BCBAs can bill under HSPP Medicaid, but it is crucial to follow specific state guidelines and Medicaid requirements. Utilizing aba therapy billing and insurance services helps BCBAs navigate Medicaid billing efficiently and compliantly. 

Adaptive behavior treatment by protocol, billed under codes like 97153, involves structured intervention plans administered by a technician under supervision. These treatments are designed to systematically address and modify maladaptive behaviors. Adaptive behavior treatment ABA focuses on enhancing the patient’s adaptive skills through repeated practice. 

Common mistakes in adaptive behavior services medical coding include insufficient documentation, incorrect insurance verification, and improper code assignment. Utilizing autism revenue cycle management services and billing services can help mitigate these errors by ensuring thorough documentation and correct code usage. 

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