Summary of Key Dates:
February 1, 2017: Applied Behavior Analysis (ABA) services will end and BA services will begin. Florida providers must be enrolled as Provider Type 39 with Florida Medicaid to bill for dates of service starting February 1 and providers must use the new BA billing procedure codes.
February 1, 2017: Provider Type 39 providers must begin submitting requests for prior authorization for behavior analysis services.
April 3, 2017: Provider Type 39 must have an approved prior authorization for dates of service starting April 3.
Explanation of Policy Changes and Requirements:
The Agency for Health Care Administration (Agency) has developed the Behavior Analysis (BA) service for Medicaid recipients under 21 years of age (herein referred to as “children”). The new service will be delivered by a specific provider type created for BA services (Provider Type 39). This new service will replace coverage of Applied Behavior Analysis (ABA) services that is currently reimbursed under the following policies: Community Behavioral Health, Early Intervention Services, and the Individual Budgeting Home and Community-Based Services Waiver.
- Effective January 1, 2017, new ABA Temporary Procedure Codes will replace the codes currently used for these services.
- These temporary codes are currently being used by some private insurance carriers.
- Multiple procedure codes will replace a current code.
- Modifiers will be required with some codes.
- An approved Behavior Treatment Plan may include group therapy that:
- Is administered by a Licensed Professional Behavior Analyst or State Certified Assistant Behavior Analyst;
- Must be face-to-face with multiple patients;
- The recipients must have similar diagnoses, behaviors, and treatment needs.
- Is administered by a registered line technician;
- Must be face-to-face with two or more patients;
- The recipients must have similar diagnoses, behaviors, and treatment needs.
- Covered Services:
- Group Adaptive Behavior – Initial 30 minutes
- Group Adaptive Behavior – Additional 30 minutes
- Adaptive Behavior Treatment – Social Skills Group – Patient Present
- Multiple-Family Group – Adaptive Behavior Treatment Guidance
- Adaptive Behavior Treatment – Social Skills Group – Without Patient
- Place of Service
- Services must be provided in a natural setting (i.e. a home and community-based setting – including clinics and schools)
- Medically necessary services provided by enrolled LBA, SCABA, or Registered Line Technicians are allowed in school settings.
The following services do not meet medical necessity criteria and do not qualify as Medicaid covered ABA-based therapy services:
- Therapy services rendered when measureable functional improvement or continued clinical benefit is not expected and, therapy is not necessary or expected for maintenance of function or to prevent deterioration;
- Service that is primarily educational in nature;
- Services delivered outside of the school setting that duplicate services under an individualized family service plan (IFSP) or an (IEP), as required under the federal Individuals with Disabilities Education Act (IDEA);
- Treatment whose purpose is vocationally or recreationally-based;
- Custodial care that:
- Is provided primarily to assist in the activities of daily living (ADLs) such as bathing, dressing, eating, and maintaining personal hygiene and safety;
- Is provided primarily for maintaining the recipient’s or anyone else’s safety;
- Could be provided by persons without professional skills or training; and
- Services, supplies or procedures performed in a non-conventional setting including, but not limited to: Resorts; Spas; Therapeutic programs; or Camps.
Tables of ABA Procedure Codes
The following tables display:
- The crosswalk from the current procedure code to the new procedure code;
- The modifier requirements where applicable;
- The description of the new procedure code;
- The service unit.
Assessment table with new procedure codes and modifiers for 2017
Treatment table featuring revised procedure codes and modifiers for 2017
Supervision table showing the 2017 procedure codes and modifiers
Group Services Not Previously Covered
Table of group services not previously covered, with revised procedure codes and modifiers for 2017
*Please remember that you have the ability to add/remove CPT codes from ClinicSource by navigating to Setup > CPT Codes.
Prior Authorization of ABA Service
- All ABA services continue to require prior authorization.
- A prior authorization period shall not exceed 180 days. Services provided without prior authorization will not be considered for reimbursement.
- LDH will honor all prior authorizations already approved and in effect prior to December 21, 2016, and will pay those services using the approved codes from the prior authorization at the rate on file on or before December 31, 2016.
- Example: A currently approved authorization for treatment with H2019 that covers service dates November 1, 2016 thru April 3o, 2017 will continue to be billed for services using the code approved on the authorization and the services will be paid at the current fee on file when the authorization was approved.
- All new prior authorization requests received with a begin date of service on or after January 1, 2017 must be submitted using the new procedure codes and will be paid at the new rates.
- Example: The current authorization for treatment approved with code H2019 (Adaptive Behavior Treatment by LBA) will end on December 31 2016 and you need to submit a new request with a begin date of January 1, 2017. You must submit your PA request using the new procedures codes (0364T TG and/or 0365T TG) and, if approved, the services will be paid at the new rates.
- Prior authorization requests submitted after December 20, 2016 which include a begin date of service before January 1, 2017 and a thru date of service after January 1, 2017 must be split and submitted as two requests.
- One request must be submitted with the current procedure code(s) to cover service dates through December 31, 2016.
- Another request must be submitted with the new procedure code(s) to cover service dates January 1, 2017 forward.
- Any e-PA requests received after December 20, 2016 with dates that overlap 2017 will be rejected.
- Example: The current authorization for treatment approved with code H2019 (Adaptive Behavior Treatment by LBA) ends on December 27, 2016. The new request for services is not submitted until December 21, 2016. You must submit two PA requests: (1) A request with a begin date of service December 28, 2016 through December 31, 2016 using the current procedure code H2019, and (2) a request using the new procedure code(s) 0364T TG and/or 0365T TG (Adaptive Behavior Treatment by LBA) with a begin date of service January 1, 2017 through the end of the period for which you are requesting authorization.
*Please remember that ClinicSource is valuable in keeping track of your Authorizations. Authorizations are tracked by Discipline and by CPT, Date Range and Unit/Visit count under the patients profile by clicking on the payer requiring the authorization. Scroll about 75% down the page and Authorizations will be there.
Unfortunately, not all insurers will pay you even if you code in compliance with CPT rules. Be sure to appeal any denied claim. A review of your documentation by the insurer may actually result in payment for your work.
We cannot stress enough that ABA Service Must Be Medically Necessary. Providers must abide by the requirements of all medical policies.
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