Focus on…Ethical Billing

Michele Silcox • CEO/Owner
ABA Therapy Billing and Insurance Services and

With the adoption of Category I CPT® Codes for Adaptive Behavior Services, ABA providers now have reimbursement codes that are permanent and signify that the clinical efficacy of the services has been documented in research that meets AMA standards. This significant accomplishment by the ABA Steering Committee is designed to start the process of more consistent adherence to the code descriptors that were approved by the CPT Editorial Panel. It will also aid in fewer denials of coverage for ABA services expressed as ABA is experimental or not medically necessary.

Intent and Implementation of the Codes

Providers have been diligently working to understand the INTENT of the codes using the resources provided by the ABA Steering Committee. Recorded webinars and other supplemental guidance and valuable information can be found at Armed with information related to the intent of the codes and being educated in the code descriptors, providers can have critical conversations with health plans about their payor policies being set during this IMPLEMENTATION phase.

Approval of the CPT® codes is not where the work ends. It will take a concerted effort from ABA providers with communication and education of health plans for proper roll out of new codes. The health plans are also learning a new code set as well. The ABA Steering Committee supports that effort with health plans and it’s us up to us to add our individual advocacy efforts and continue the process. Advocacy can be confusing, frustrating and sometimes difficult, but it’s important to remember that you have a seat at the table with your health plan contracts and your voice matters!

Ethical Billing Practices

During this time, don’t lose sight of Ethical Billing practices to keep your organization out of harm’s way of unintended fraudulent billing or what may be perceived as abuse in an audit.

Below are some tips you may consider in this effort:

  1. Be sure your internal team or outsourced billing company is using all available resources and is well versed in the intent of the codes and staying connected with published payor policies for each health plan you work with.
  2. Recognize that some health plans were using the Category III codes in non-standard ways. For example, TRICARE independently utilized 0360T/0361T for Supervised Fieldwork which was a non-standard use of a code that did not correlate with this service. Other health plans had granted authorization and/or given guidance to use the Category III codes for non face-to-face activities, despite the language of the code referencing Category III codes were also for face-to-face activities.
  3. Ground yourself in the difference between Case Supervision and supervision related to an RBT certificant. Many activities performed during Protocol Modification while simultaneously directing a technician may qualify for the certificant supervision requirements, but some may be considered practice and overhead expense.
  4. Know that there could be a period of time where there is not a stand-alone code for indirect services and plan accordingly.
  5. Work with your local ABA Chapters and/or local ABA providers in your advocacy efforts. There are ways to collaborate that don’t violate anti-trust laws. Be well versed in what is considered a violation and steer clear of those activities; but work together collectively in your mission to educate and train the health plans to better understand the intent and implementation needs.