New CPT Codes

The creation of these new codes for adaptive behavior services will make reporting of adaptive behavior therapy services much easier. Although the codes are not listed with Relative Value Units (RVU’s) on the Medicare Physician Fee Schedule, they may be considered for payment by Quartz based on each provider’s contract agreement.

Prior to the update on January 1, the CPT codes available included a code for the first 30 minutes of treatment and assessment. If the encounter extended beyond 30 minutes an additional code was required. In addition, “untimed” codes were available.

Now, in 2019, the codes are streamlined – each unit is 15 minutes – no add-on codes are needed. This simplification should create uniformity in billing practices and also reduce the chance of denials due to coding errors.

An additional benefit resulting from these new codes is the clarification of the level of provider preforming the service (MD, PA, technician). Further, a separation of codes to distinguish computerized testing with automated results (96146) and testing and evaluation by a provider (96136 – 96139) is available.

Correct coding of adaptive behavior services will result in accurate and timely claims processing, providing a better experience to our members and their caregivers.

Please contact your Provider Coordinator if you have questions regarding the use of appropriate coding and billing requirements.

Helpful Tips

Here's how to use some of the codes for the same patient during the same time period.

According to CPT, 97155 can be billed in two instances – alone or with 97153.

• To do this, both the provider and the technician would be billed during the same time period.

97153 and 97156

• 97153 is face-to-face treatment of the patient using the established protocol.
• 97156 is face-to-face training of the patient’s family about the established protocol. This code doesn’t require the patient to be present for the family training session.

97157 and 97153

• 97157 is face-to-face with a group of parents, specifically without the patient present
• 97153 is face-to-face treatment of the patient

1. 97154 is used for group treatment with two or more patients
2. 97155 is used for one provider with one patient face-to-face

Rationale: a provider cannot be face-to-face with the patient and also be face-to-face with the family during the same time period, they are mutually exclusive; secondly 97153 requires the patient present to treat the patient.

97156 does not require the patient to be present during the family education period.

To bill for the same time period, you must include at least two technicians

Rationale: mutually exclusive by definition.

Two separate treatment areas are requiredin order to bill at the same time: one area including a provider, one area including the tech.

97155 and 97154

• According to CPT, 97155 can be billed in two circumstances – alone or with 97153.
• These codes must be used with two different patients –
  • You may not bill both codes at the same time for the same patient.

Correct coding of adaptive behavior services will result in accurate and timely claims processing, providing a better experience to our members and their caregivers.