Avoid ABA Therapy Modifiers and Code Combination Errors

Mastering ABA billing requires staying up-to-date with the latest modifiers and CPT codes. Accurate coding is essential for an ABA therapy center to bill insurance successfully.

Each claim must include a Current Procedural Terminology (CPT) code and a modifier, which detail the specific service provided and the credentials of the healthcare provider. Using incorrect codes or modifiers can lead to claim denials, complicating and delaying the process.

To avoid errors and streamline your claims, explore our comprehensive guide below.

ABA Therapy Modifiers

An ABA billing modifier is a code used to describe the credentials of a healthcare provider, such as a doctor or therapist. Navigating ABA modifiers can be challenging because every insurance company and state has different requirements. Also, the ABA modifier and ABA billing codes have to be correct and case-appropriate on an insurance claim.

Some insurance payers also use modifiers to show who was present at the treatment session. Modifiers differ by state, type of service, and payer and provider credentials.

The four most common ABA billing modifiers include:

The HO modifier denotes that the ABA supervisor rendered the services indicated by the CPT code. The supervisor usually has a master’s degree, indicating a Board Certified Behavior Analyst (BCBA). For instance, a therapist with a Master’s in Social Work would use the HO modifier on the claim.
The HN modifier describes that the service was rendered by a trained provider with a bachelor’s degree. The healthcare provider can be a Registered Behavior Technician (RBT) or a Board Certified Assistant Behavior Analyst (BCaBA).
The HP modifier is for providers who are at least at a doctoral level, like a BCBA-D. This is the highest level of qualification in the field of ABA therapy.
The HM modifier denotes any provider or behavior technician without a bachelor’s degree. The technician would have to deliver ABA therapy under the supervision of a qualified behavior analyst.

ABA CPT Codes

As for ABA CPT codes, these are a set of numbers used to describe ABA treatments and services. There are 10 CPT codes in the field of ABA therapy that are used to describe client assessment tasks, interventions, and treatments. The CPT code should be entered in the insurance claim along with the modifier. Here is a brief look at the ABA CPT codes based on the ABA Coding Coalition used by Medicaid and other payers.

Adaptive Behavior Assessment – Category I

97151: Behavior identification assessment administered by a physician or other qualified health care professional.
97152: Behavior identification supporting assessment administered by a technician under the direction of a physician or other qualified health care professional.

Category II

0362T: Behavior identification supporting assessment, every 15 minutes of the technician’s time face-to-face with a patient that exhibits destructive behavior.

Adaptive Behavior Treatment – Category I

97153: Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified health care professional.
97154: Group adaptive behavior treatment by protocol.
97155: Adaptive behavior treatment with protocol modification.
97156: Family adaptive behavior treatment guidance administered by a physician.
97157: Multiple-family group adaptive behavior guidance.
97158: Group adaptive behavior treatment with protocol modification.

Category III

0373T: Adaptive behavior treatment with protocol modification for a patient with destructive behavior and the assistance of two or more technicians.

Tips for Avoiding Common Errors in ABA Therapy Modifiers and CPT Codes

As we’ve discussed, even a single incorrect digit in a CPT code or an error in a modifier can result in a claim denial. It’s important for ABA therapy centers to avoid any errors related to these codes if they want a seamless revenue management process. Here are some tips to keep in mind when using CPT codes and modifiers in your insurance claim.

Understand the Insurance Company’s Requirements

First, you need to understand the specific requirements of the insurance company your healthcare center is working with. Every insurance payer has its own rules for modifiers and code combinations. Also, make sure the services and codes are approved for billing, and if the codes are restricted, you can claim them per day or week.

Use Modifiers Properly

It’s highly essential to use your modifiers properly if you want to avoid a claim denial. The primary ABA codes should be attached with the correct modifiers based on who performed the service. If multiple modifiers are required in the claim, use the most specific modifier first. In addition, if there was supervision during the treatment, you should use the appropriate modifiers.

Avoid Wrong Code Combinations

The CPT codes can also be tricky when submitting an insurance claim. If two services are provided at the same time, be cautious about the billing. For instance, 97153 is adaptive behavior treatment by protocol, while 97155 is the adaptive behavior treatment with protocol modification and can be administered at the same time. Make sure there’s appropriate documentation for concurrent services.

Make sure the billed time does not exceed the total time available in a day. Also, there should be no overlapping services. For instance, if you administer group therapy with code 97158 and individual therapy with code 97153 on the same day, make sure they are billed separately.

Check Time-Based Billing

Some CPT codes, like 97155, have 15-minute increments, so ensure that the billing matches the service time. Each payer has different rules for rounding up or down, so follow the specific rules and avoid billing for more time than documented or allowed.

Document Thoroughly

Your insurance claims should be thoroughly documented to avoid being denied. For one, include specific details on who provided the service, the session progress, and the specific goals being addressed. Also, make sure the start and end times are properly recorded for time-based billing. If the ABA technicians are supervised by another professional, it should be documented.

Conduct Regular Compliance Audits

Claims must be constantly reviewed to identify and correct errors before they are submitted. Staff should also be regularly trained on the best practices for billing and documentation.

Use ABA Billing Software

It’s a good idea to use ABA billing software that flags invalid CPT combinations or missing modifiers. This can help to prevent errors. Some of these software can verify authorization hours and assign CPT codes. You can consider integrating ABA billing into the revenue cycle management process to ensure accurate claims.

Follow the Best Practices for ABA Billing

Your medical insurance claims should include the correct CPT code and modifier if you want to avoid delays in the processing and denials. It’s essential to train your staff on the best practices for using these codes and modifiers. Another good idea is to work with a third-party billing service that can help you handle all your ABA billing needs, so they can help reduce your denials and errors.