Education & TrainingMedicaid Managed CareOctober 18, 2023

Applied behavior analysis services

Anthem Blue Cross and Blue Shield (Anthem) reimburses for state and federal required covered services as part of a comprehensive plan of care for members with autism spectrum disorders (ASD) through every stage of life when ordered by a licensed physician — such as a pediatrician or psychiatrist — and provided by a certified, credentialed, and/or licensed Anthem participating provider therapist. Anthem supports early intervention services and therapies for the treatment of autism spectrum disorders, including physical, speech, and occupational therapy, as well as psychological/psychiatric services.

No hard limits apply to these services. Services will be prior authorized according to medical necessity criteria.

Provider Network Management (PNM) enrollment for applied behavior analysis (ABA) providers

To ensure the prompt and timely payment of claims for services rendered to Ohio Medicaid Managed Care members, providers must be enrolled with Ohio Department of Medicaid (ODM) and active in the Provider Network Management (PNM) module. Refer to the ODM website for more information.

ODM currently does not have a recognized provider type for ABA. Anthem will accept claims for ABA services for entities who are registered and active in the PNM as provider type 21 (professional medical group). All rendering providers will need to be active and enrolled in the PNM as provider type 19 (managed care organization). Provider types 21 and 19 will be recognized until the ODM designated provider type is established.

Coding implications

Codes referenced in this bulletin are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT ® code

Description

97151

Behavior identification assessment, administered by a physician or other qualified healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare 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 healthcare professional, face-to-face with multiple patients, 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 healthcare 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 healthcare 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

ICD-10-CM diagnosis codes that support coverage criteria

ICD-10-CM code

Description

F84.0

Autistic disorder

F84.2

Rett syndrome

F84.3

Other childhood disintegrative disorder

F84.5

Asperger’s syndrome

F84.8

Other pervasive developmental disorders

F84.9

Pervasive developmental disorder, unspecified

OHBCBS-CD-041518-23

PUBLICATIONS: November 2023 Provider Newsletter