New codes for adaptive behavior assessment take effect
New CPT® Category III codes for reporting adaptive behavior assessment/intervention services (ABA) for the assessment and treatment of Autism Spectrum Disorders just took effect for services delivered on or after July 1, 2014. In total, there are 16 codes (0359T through 0374T) to report behavior identification assessment, observational behavioral follow-up assessment, exposure behavioral follow-up assessment and adaptive behavior treatment. The new ABA codes pertain to services commonly known as applied behavior analysis.
Because these codes are part of a midyear release, they and their descriptors are available online at the American Medical Association (AMA) website. To access the code information, you may be asked to create an account free of charge. The codes will also appear in the 2015 CPT manual published by the AMA.
Several basic questions and answers about the new codes follow.
Q: What is a CPT Category III code? How does it differ from other CPT codes?
A: In general, the CPT Category III codes allow health care professionals, insurers, health care researchers and policy experts to identify new and emerging services, procedures and technology. The codes are sometimes used to track how frequently a particular service is provided. The format of Category III codes is alphanumeric, with four digits followed by the letter “T.”
Category I codes — the ones most familiar to most psychologists who bill insurance plans — describe established health care services and procedures and technology. The format of Category I codes is five-digit numeric.
Q: Where do I find details about how to use the new adaptive behavior assessment codes?
A: For additional details about how to use the codes correctly, please refer to page 6 of the American Medical Association’s CPT Category III Codes document or the 2015 CPT manual when it becomes available in late 2014. Practitioners who use these new codes should familiarize themselves with restrictions that apply to using combinations of the new codes with designated Category 1 codes.
[Updated Aug. 19, 2015] In addition to listing the new codes, the AMA has uploaded an article from its CPT Assistant publication (PDF, 266KB, registration required) that explains the correct use of the ABA codes.
Q: Will insurers and government programs pay for services billed with the codes?
A: Some form of coverage for ABA services is mandated for health insurance in most states. In states without mandates for these services, insurers and state/local government health programs — such as Medicaid — might elect to use some or all of these codes; others might continue to use different, existing codes (such as Healthcare Common Procedure Coding System [HCPCS] codes H0031, H0032, etc.). Check with the state program or health plan to confirm which codes will be accepted.
Medicare will not assign fee amounts for Category III codes in its fee schedule. Under Medicare, new Category III Codes are considered noncovered unless specifically approved for payment by CMS or by the Medicare Administrative Contractor’s (MAC) medical directors. In such case, the MACs will publish a local coverage determination (LCD) or article on their website.
Additional resources for CPT code book include: