Are you an applied behavior analysis (ABA) therapist stuck between clinical responsibilities and time-consuming administrative tasks, including medical coding? We understand CPT codes can be confusing! It is surrounded by many questions – from whether it is a timed code or not, to if you can bill one code with another, and so on.
Thus, we decided to start a CPT code library, where each blog will discuss all the elements of one procedural code. This blog will revolve around the 97151 CPT code. We will discuss its description, where you can apply it, and what factors you should consider while billing it. We will also cover frequently asked questions related to it.
97151 CPT Code – Description
The CPT code 97151 is from the Adaptive Behavior Assessment Procedures range, as maintained by the American Medical Association (AMA). It involves maladaptive or adaptive behavior identification, where a qualified healthcare professional (QHP), physician, or provider employs various in-person tests to assess the patient’s behavior.
Besides conducting different evaluation tests, the healthcare provider also scores the tests, interprets the results, tailors a treatment plan, generates reports, and communicates the specifics with the caregiver, guardian, or parent.
You can bill this code for every 15 minutes the practitioner spends with the patient in person, along with the non-face-to-face time required to analyze the past data. The maximum billing limit for the 97151 CPT code is 32 units or 8 hours.
Scenarios Where CPT Code 97151 is Applicable
There are several scenarios where you can apply the CPT code 97151, but in this section, we will only discuss a few.
ASD Evaluation
Consider an adult or a child who has been referred for an initial evaluation for potential autism spectrum disorder (ASD). A qualified healthcare professional can report the 97151 CPT code to bill the initial assessment. It may involve reviewing medical records, collecting data, and performing standardized assessments to evaluate the patient’s behavior, including daily living, social, and communication skills.
Supported Living Services Eligibility
Supported living services are provided to individuals with developmental disabilities to help them live independently. Thus, the healthcare provider may report CPT code 97151 for conducting the eligibility assessment to determine whether the patient requires these services.
ADHD Reassessment
Assume a situation where a child has executive function difficulties and attention deficit hyperactivity disorder (ADHD). Thus, they require regular assessments to not only track the progress but also to update the treatment plan accordingly. The provider may use the 97151 CPT code to bill these reassessments.
Things to Consider While Billing CPT Code 97151
Discussed below are some of the main factors you should consider while billing the 97151 CPT code:
Appropriate Use of ABA Modifiers
The proper use of ABA modifiers is essential to ensure you receive accurate 97151 CPT code reimbursement. These modifiers help insurance payers determine the healthcare provider’s qualifications.
Some of the most common modifiers are listed below:
- HN – It indicates a bachelor’s level practitioner, such as BCaBA or RBT.
- HO – It represents a master’s level practitioner.
- HP – It specifies a doctoral-level practitioner.
You should always strive to document the correct professional level by adding the appropriate modifier since it directly impacts the reimbursement rates. If you fail to add a modifier, the payer will assume that a BCaBA performed the assessment. Thus, we recommend you recheck every claim before submission for any errors. Inappropriate use of modifiers may lead to incorrect reimbursement, payment delays, or even denials.
Verify Provider Qualification
You should ensure that the initial assessment is performed by a QHP, physician, or provider. Also, verify that the clinician who conducted the evaluation is enrolled and credentialed with the insurance company to bill the 97151 CPT code.
Comprehensive Documentation
Next, you should provide detailed documentation while reporting the CPT code 97151. It may include referral details, patient history and behavioral concerns, information related to assessment tools and measures, observations and clinical findings, diagnosis, and the proposed treatment plan.
Besides, you should document the time spent assessing the patient. This time may include all the non-face-to-face and face-to-face activities.
Determine the MUE Policy
Each payer follows a different medically unlikely edit (MUE) policy for reimbursing CPT codes. MUE can be defined as the maximum number of billable units by a clinician against a specific CPT code, like 97151, for a single patient in one day. Billing for more than what is specified may result in claim denial or a reduction in payment.
If we talk about the 97151 CPT code, Medicare’s MUE is 8 units, while Medicaid’s MUE is 32 units. Thus, even if you want to submit a claim to a commercial payer, you will have to check whether they are following Medicare or Medicaid’s MUE.
Summary
This guide provided a detailed description of the CPT code 97151 and scenarios where it is applicable, including ASD evaluation, ADHD reassessment, and eligibility checks for supported living services. Moreover, we shared the factors to consider while billing the 97151 CPT code, such as determining the payer MUE policy, ensuring comprehensive documentation, verifying provider qualification, and using appropriate ABA modifiers.
We hope that this guide presented the information you were looking for. However, if you believe medical billing is not your cup of tea, we recommend outsourcing it to professionals. At MediBill MD, we offer tailored ABA therapy billing services to help therapists streamline their coding and billing workflow.
Frequently Asked Questions
