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Temporary CPT Codes

The American Medical Association (AMA) released a set of temporary Current Procedural Terminology (CPT) billing codes for ABA evaluation and treatment services several years ago to aid payers and practitioners in their development of billing systems for emerging ABA therapy.

There has been some confusion in regards to these codes, especially the Initial Untimed Behavior Identification Assessment code (0359T), as well as the Observational Behavioral Follow Up assessments codes (0360T and 0361T respectively).

Unfortunately, the use of these codes has not been uniform across services and insurances, so that when deciding which billing codes to use, it is vital that you only use those for which you have written approval to do so from the insurer’s health plan. Some carriers have adopted the temporary CPT codes, while others have/will not.

Again, attend to the codes in your contracts and the applicable rates. Organizations such as APBA, ABAI, BACB, and Autism Speaks are working on legal proposals to help alleviate some of these issues, but the codes will likely remain in place for a few more years before any changes will occur.

Rates for CPT Codes

These CPT Category III codes are temporary, and because of this, have no nationally recognized value. Currently, each insurance company negotiates reimbursement rates by geographic region.

As an ABA practitioner, you should not file reimbursement claims until you are able to verify that the insurer for your patient has appropriate coverage and accepts these codes.

Code 0359T

The American Medical Association describes 0359T as:

“Behavior identification assessment by the physician or other qualified healthcare professional (QHCP), face-to-face with patient and caregiver(s). Includes administration of standardized and nonstandardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report.”

Generally, all clients will receive an initial assessment (0359T), which will be reported once and is estimated to take 90 minute of QHCP time—though it could take more or less time. However, code 0359T is not a time code and cannot be billed in increment. Insurers usually develop plan coverage payment to the “typical” time allotted for a service. Because office time may be required to effectively develop a treatment plan and report, these costs should be include in a practice’s expenses.

Additionally, 0359T may be used to report a reassessment. This is usually required after the success or failure of a current treatment, which requires new or revised treatment goals. Code 0359T may also be reported for an assessment required for early intensive behavioral intervention (EIBI).

Depending on the results of this initial assessment, the QHCP will decide whether or not additional assessments are required and will develop a treatment plan accordingly. This may mean directly proceeding to a treatment for uncomplicated problems.

Observational Behavioral Follow-up Assessment Codes 0360T and 0361T

Once the initial assessment has taken place and a treatment plan developed, all clients will receive an observational behavioral follow-up assessment that is coded as either 0360T or 0361T (for an ABLLS, AFLS, and one BCaBA).

0360T is identified as:

“Observational behavioral follow-up assessment. Includes physician or other qualified healthcare professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient.”

0361T is identified as:

“Observational behavioral follow-up assessment. Includes physician or other qualified healthcare professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (list separately in addition to code for primary service).”

Code 0359T may be followed by procedures 0360T and 0361T by technicians who are directed by a QHCP. This data collected during these follow up sessions are utilized by the QHCP as baseline data and are used to help develop specific behavioral goals for the patient’s treatment plan.

Code 0360T can only be reported once per day for the first 30 minutes of a technician’s face-to-face with a patient, while code 0361T can be reported in multiple units. However, please be aware that the insurer may cap the frequency of 0361T.

Make sure to adequately detail the benefits of treatment.

Documenting Time

While the assessment and treatment codes include stand-alone codes for the first 30 minutes and add-on codes for each additional 30 minutes, it is still important to document time. The format to document time is dependent on each ABA practitioner, but should be maintained for billing purposes.

Remember that insurers may request documentation (including time) to ensure that the services provided are meeting medical necessity. Failure to provide effective documentation can mean coverage and reimbursement denial.

Amvik Solutions can help you deal with the pressures of billing and understanding CPT codes.

Insurance companies can be challenging to work with; that’s why you need a partner that can help you to catch mistakes that the insurer, or even your own billing department, may make.

At Amvik Solutions, we follow up with insurance companies and funding sources to ensure that everything is paid correctly and authorization does not end prematurely. Because cash flow is the life of your clinic, we work hard to make sure that you have a steady stream of reimbursements coming in.

Insurance companies usually lag when it comes to payments, especially when there’s changes to regulations and coding within the field. Amvik Solutions can stay on top of every change so you don’t have to worry.

Benefits include:

  • Electronic claim submission whenever possible or paper claim submission if required by funding source
  • Unpaid and denied claims follow up with insurance companies and funding sources
  • Patient responsibility invoicing and follow up
  • Claims follow up through collection agency
  • Client eligibility and benefit verification
  • Regional Center co-pay/co-insurance coordination
  • Comprehensive reporting – account ledger & claims denial report including an action trail documenting follow up correspondence with insurance companies and funding sources

Contact Amvik Solutions today at (805) 277-3392 to find out about more about the one source for all billing requirements.