Did you know that 1 in 31 children in the U.S. is diagnosed with autism spectrum disorder (ASD)? Luckily, applied behavior analysis (ABA) therapy has a success rate of approximately 89%. However, billing for ABA therapy sessions is complex, as it involves several factors. Time tracking, detailed session and progress notes, and following the 8-minute rule are just a few complexities.
Thus, we decided to dedicate this guide exclusively to discussing the billing requirements for CPT code 97153 to help you bypass denials and audits. We will explain its descriptor, share clinical scenarios, list applicable modifiers, and much more.
So, without further ado, let’s get started!
CPT Code 97153 – Description
CPT code 97153 covers every 15 minutes of face-to-face technician (supervised by a physician) time spent with a single patient to administer adaptive behavior treatment.
The treatment covered under this timed code primarily targets conditions such as developmental disabilities (maladaptive or adaptive behaviors). Moreover, the technician administers the service as per an established protocol.
The table below offers an at-a-glance view into adaptive vs. maladaptive behaviors:
| Maladaptive Behavior (Target for Reduction) | Adaptive Behavior (Goal) | |
|---|---|---|
| Social Skills | Screaming, crying, and engaging in tantrums or whining to get attention or access to a desired item. | Promoting functional communication using words, gestures, etc. |
| Communication | Avoiding group settings or running away from caregivers and teachers in public settings. | Forming a habit of reciprocal interaction. E.g., taking turns in a game, etc. |
| Safety | Head banging, biting, or scratching oneself. | Following simple safety directions, e.g., hold, stop, etc. |
| Independence | Refusing to attempt self-care tasks. | Independently dressing, following a visual schedule, etc. |
| Emotional Regulation | Biting, kicking, or hitting others when frustrated. | Demonstrating coping skills, e.g., taking a break, counting to ten, etc. |
| Eating/Hygiene | Ingesting non-food items. | Accepting different foods and using utensils appropriately. |
Scenarios Where CPT Code 97153 is Applicable
Review the following real-world clinical scenarios to understand the application of CPT 97153:
Language Acquisition and Social Skills
Picture a 7-year-old boy with ASD who has been receiving in-home therapy. A board-certified behavior analyst (BCBA) designed the established protocol. It aims to target reciprocal social skills (making eye contact, taking turns) and functional communication skills.
A registered behavioral technician spends 60 minutes working face-to-face with the boy. During the encounter, the technician performs natural environment teaching (NET) and discrete trial training (DTT) under the direct supervision of the BCBA.
Here, the technician will report 4 units of CPT code 97153.
Severe Maladaptive Behavior (Self-Injury)
Assume a 15-year-old non-verbal female patient with a developmental disability. She has been exhibiting severe self-injurious behavior (SIB), e.g., head banging.
Thus, the physician designs an aggressive, positive behavior support plan. It involves functional communication training and extinction procedures.
The technician spends 75 minutes of direct, intensive intervention. Activities performed during the encounter include proactively redirecting the patient and reinforcing appropriate behavior. Moreover, the technician collects data on the frequency and duration of SIB episodes.
Following the 8-minute rule, the technician should bill 5 units of CPT code 97153.
Focus on Adaptive Daily Living Skills (ADLs)
Imagine a 14-year-old boy with limited independent living skills. He has an established protocol that focuses on ADL training, specifically dressing and toileting.
Thus, the technician spends 90 minutes with the patient to teach him the complex steps of independent dressing and toileting.
Here, 6 units of CPT code 97153 are billable.
Applicable Modifiers for CPT Code 97153
Listed below are some of the applicable modifiers for CPT 97153:
Modifier 95 or GT
Since CPT code 97153 is a telehealth-approved service, you should append modifier 95 or GT if the technician performed the session using a synchronous real-time audio and video telecommunication system.
Note: GT and 95 indicate the same thing. However, most payers recognize modifier 95. Thus, you should always check with the relevant payer to determine which modifier they prefer for telehealth services.
Modifier HN or HM
Some insurance payers may require you to append a modifier to specify the role of the provider performing the ABA service covered under CPT code 97153. Thus, based on the provider type, choose the relevant modifier to meet payer guidelines:
- Modifier HN: It indicates that the highest degree the rendering provider holds is a bachelor’s degree level.
- Modifier HM: It represents that the rendering behavioral technician has less than a bachelor’s degree.
Modifier XE
What happens when the same technician performs the same service (CPT code 97153) in two or more distinct face-to-face treatment sessions with the patient on the same date of service? In case there is a significant break between the two sessions, e.g., morning session and afternoon session, you append modifier XE while billing for the second session.
Let’s take a look at an example! The technician conducts the first session from 8:00 am to 9:00 am. He then performs the afternoon session from 1:00 pm to 2:15 pm. As you can see, there is a significant time interval between the two encounters.
Thus, you should report the services like this:
- Column 1: 97153 x 4 units
- Column 2: 97153-XE x 5 units
CPT Code 97153 – Billing & Reimbursement Guidelines
Expedite reimbursements and ensure a steady cash flow by following the proper billing guidelines for CPT 97153:
Daily Session Notes & Time Tracking
Comprehensive daily session notes and accurate time tracking are key to ensuring you get paid for all the billed units of CPT code 97153. Here’s what your documentation must include:
- Precise recording of the start and stop times of the session with the patient to calculate the billable units as per the 8-minute rule.
- A justification of the billed units by documenting the total session time.
- The location where you rendered the service (e.g., home, school, etc.) with the relevant place of service (POS) code.
- Complete session notes with the signature of the technician. Besides, do not forget to include their credentials and degree modifier (e.g., HM, HN).
Treatment Delivery & Progress Notes
Your treatment delivery and progress notes should confirm the following about the rendered therapeutic service to ensure accurate reimbursement against CPT code 97153:
- List the specific, measurable goals from the treatment plan that the technician addressed during the session.
- Explain the type of ABA techniques used, e.g., functional communication training, etc.
- Document the collected data during the session, e.g., the frequency count of maladaptive behavior, percentage of correct responses, etc.
- Provide a summary. It should include the patient’s engagement, any major behavioral episodes during the encounter, and progress made toward the daily objectives.
Proof of Supervision
Note that CPT code 97153 is for billing the direct, face-to-face time spent conducting the session. That is, the supervising physician has their specific codes to report, such as CPT 97155. Yet, the technician’s notes must indirectly establish that they worked under clinical supervision.
So, you must include the following:
- Explicitly state that the technician followed the established protocol and did not modify the treatment independently.
- Mention the name and credentials of the supervising physician.
Summary
With that said, it is time to bid farewell. However, before that, here’s a quick rundown of what we discussed in this guide!
We learnt that CPT code 97153 covers 15 minutes of direct, face-to-face technician time spent with the patient administering adaptive behavior treatment. You can bill multiple units as per the 8-minute rule.
Besides, while billing for the service, you must ensure to append the relevant degree modifier, e.g., HM or HN.
That’s not all, we also explained the reimbursement guidelines. These include time tracking, recording treatment delivery details, and maintaining daily session notes, progress notes, and proof of supervision.
Hopefully, this guide will serve as a go-to resource when billing for CPT 97153. However, if you still struggle, feel free to outsource ABA billing services to MediBillMD.
