Understanding ABA Regulations to Get Your Money’s Worth

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It’s been some time since the health insurance companies and government programs first began to acknowledge Applied Behavior Analysis as a treatment that may be medically necessary for the continued well-being of a patient. Before this therapy was something that health insurance would consider paying for, no billing codes existed for this particular treatment. Therapists and professionals would have to use generic codes in their billing, but thankfully times have changed! ABA billing now has its own codes, which makes reconciling accounts a lot easier for the medical professionals, the patients, or people paying for therapy services, and you – the people who process the claims and try to get clients the most out of their coverage.

Currently, there are a total of 16 CPT codes that guide the way ABA therapy is billed and paid out. These codes and payment yes or no’s can be complicated and confusing, especially if you are new to the system. It can be challenging to know how to process a claim for the maximum amount if you don’t understand the complexities of the codes and how to use them. In this article, we’re going to explore the codes and regulations and help you understand what’s really going on behind all those numbers.

ABA Codes

Here are the most common ABA billing codes you’re likely to see:

  •  97151 – Behavior Identification Assessment  
  • 0362T – Exposure Behavioral Follow-Up Assessment  
  • 97155 – Adaptive Behavior Treatment w/ Protocol Modification  
  • 97156 – Family Adaptive Behavior Treatment Guidance  
  • 97157 – Multiple Family Group Adaptive Behavior Treatment Guidance  
  • 0373T – Exposure Adaptive Behavior Treatment with Protocol Modification  
  • 97152 – Observational Behavioral Follow-Up Assessment  
  • 97153 – Adaptive Behavior Treatment by Protocol  
  • 97154 – Group Adaptive Behavior by Protocol  
  • 97158 – Adaptive Behavior Treatment Social Skills Group  

These codes fall into two broad categories. The first one uses the following codes:

  • 0360T: Observation assessment sessions below 30 minutes 
  • 0361T: Observational assessments longer than 30 minutes 
  • 0362T: Exposure behavioral assessment below 30 minutes 
  • 0363T: Exposure behavioral assessment longer than 30 minutes 

This category deals with behavior (observational and exposure) assessment and identification and can include follow up procedures.

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The second category of codes stretches from 0364T to 0374T and covers the different treatments or therapies offered to patients who need help. Some time-based sessions may have more than one billing code, so check carefully under the definition of the services rendered to make sure you include everything. As the profession continues to grow and branch out into new specializations, these codes will change and grow in number, but for now, these are the basics. Understanding the definitions attached to these codes will give your clients peace of mind because they know you’re doing the most you can to stretch their coverage by applying all the codes that tick the boxes they use. Thankfully, it’s not just you and your calculator in the Wild West of insurance claims. There is software specialized to work with ABA codes and practices that will optimize your efforts and streamline your system. This billing software helps you add up the claims and offers daily billing reports that can help you track growth and identify any gaps in payments or where you could be claiming more for a client. You can also use this software to invoice for outstanding bills and help bill payroll for your staff.

Helpful Tips

Staying up to date is essential because we’re working with a moving target here. It might seem sensible that alerts are issued when new codes are released, but it may not always be the case! It’s up to you to ensure you know as much as possible to offer the highest possible level of service at all times.

Clients don’t always understand the in’s and out’s of their policies as well as you do. If there is some dispute or confusion about what is covered and what is not, spend some time with your clients, helping them get to grips with the fine print. This shows that you care about clients and will make it easier for them to come to you for clarification in the future. Make sure you confirm coverage eligibility before assuring them any therapy or treatment will be covered.

Wrap Up

Keep your wits about you and keep your eye on the ball, and you’ll have no issues billing your clients for ABA Therapies.