In this article, you will learn about CPT code 97153, how it is documented and administered, the pre-authorization of 97153, applicable modifiers with 97153, and the frequently asked questions about 97153.
What is 97153 CPT Code?
It is a medical procedural code the American Medical Association (AMA) maintains. The American Medical Association CPT editorial panel released a new list of category 1 codes for billing Applied Behavioral Analytics (ABA) therapy services, as for many years, the ABA therapy providers and receivers faced inconsistent coverage and reimbursement policies. These new codes help standardize the billing and payment processes for ABA providers.
97153 is a category I code. This code covers adaptive behavior treatment procedures. The conditions, such as developmental disabilities, associated with adaptive or maladaptive behavior, such as poor social skills and communication, are focused on while administrating adaptive behavior treatment procedures. A technician or a healthcare professional provides these treatment services according to an established protocol. A physician or other relevant qualified healthcare professional must supervise the technician. After each 15-minute face-to-face session with one patient, report this code.
97153 is a five-digit extended numerical code. Centers for Medicare and Medicaid Services (CMS) and other third-party payers can use this code.
How is 97153 documented?
Documentation of the 97153 CPT code is vital to ensure the services and their reimbursement to improve the overall healthcare service. The following are some of the key points to consider while documenting 97153:
- Mention the date and duration of a session clearly before documenting anything else. It will help record the frequency and length of treatment to prepare the claim accordingly.
- If it is a group therapy session, a clear indication of the number of patients with their specific age range and other relevant demographic information will help record the healthcare services the technician or physician provided.
- The session’s target skills must be described and documented in the report. Those skills may include many cognitive demands, for example, attention, memory, problem-solving, and perceptual skills.
- All the activities conducted during a therapy session are explicitly documented, along with the therapeutic goals of each activity and their relevance to the targeted treatment outcomes.
- Report the response to the patient, each session’s progress, and any improvements, challenges, or observations related to cognitive function. This documentation will help track the sessions’ effectiveness and any changes required to make that procedure more effective.
- Individual modifications must also be documented according to each patient’s needs in a group therapy session.
- Document any consultations, coordination of care, or discussions with the patient’s primary physician or other healthcare professionals clearly for accurate billing and claim submission.
- The technician or healthcare professional running the session should have a datasheet with mentioned dates, times, services, locations, and the guardians’ signatures and the technician or healthcare provider himself. Follow for every face-to-face session. Justify it with the help of documented goals and quantitative data.
The following are the most important documentation requirements:
- Document the time in and the time out for the session
- The names of staff and caregiver(s) present during the session
- POS (place of service)
- Goals already addressed and data collected
- The signature of the renderer
Administration of 97153:
Registered line technicians approved by the payer ( Registered Behaviour Technicians (RBTs), Relational Life Therapists (RLTs), or Board Certified Assistant Behaviour Analysts (BCBAs)) administer this code.
It is a category I CPT code, billed in 15 minutes. It is a direct treatment code; 1-hour session equals four units. If the technician performs a comprehensive treatment plan, requesting between 20- 40 hours per week is advisable, depending on the client’s requirements.
The session needs to be face-to-face between the client and the registered technician. The services included in this code are DTT (Discrete Trial Training), NET (Natural Environment Training) activities, behavioral modification protocols, task analysis, and cognitive skills development.
It is necessary to program the code under the direction of BCBA or other qualified and relevant healthcare professionals. This code can be billed concurrently with 97155.
The administration of the code must align with the units per week established via prior authorization (PA).
Prior authorization is also known as pre-authorization or pre-certification by insurance companies to determine if specific medical services approaches are medically needed and eligible for coverage.
Prior authorization involves obtaining approval from the insurance provider before initiating and providing the services.
Applied Behavioral Analytics (ABA) requires prior authorization to submit claims for behavior treatment services, a comprehensive behavior treatment, focused behavior treatment, family treatment guidance, behavior treatment with protocol modification (under CPT 97153), team meetings, and group sessions. A licensed supervisor must list as the billing or rendering provider on a prior authorization request.
How to take Prior Authorization for CPT 97153?
- The health provider, technician, or billing staff must contact the insurance company before initiating the services to verify the coverage and determine the prior authorization requirement for 97153.
- After verifying, the healthcare provider must submit the supporting documentation as evidence of medical necessity and the determined goals of the therapy. These documents may include the patient’s medical records, assessment or diagnostic reports, treatment plans, expected outcomes, and other relevant information.
- After receiving the relevant information, the insurance company reviews the documents and determines whether they meet their criteria for service coverage. The insurance company may involve medical professionals or review specialists to determine if therapy complies with the payer’s accepted standards and the insurance plan’s guidelines.
- Once reviewed, the insurance company communicates with the healthcare provider about their decision. The provider will proceed with the services under 97153 after the approval of the claim. On the other hand, the insurance company has to provide reasons for denying the claim, such as insufficient medical necessity, limited documentation, limitations on coverage, and many other factors.
- The health care providers must familiarise themselves with the pre-authorization requirements of their insurance company. Failure to obtain pre-authorization in such cases may result in the denial of payment, burdening both the provider and the patient and leaving the patient responsible for the amount of the service.
Required modifiers for 97153:
The modifiers are essential for the proper billing process and accurate service delivery. The following are some of the modifiers with 97153.
This modifier describes the comprehensive level of service. It covers high-intensity early intervention comprehensive behavior treatment.
This modifier describes a focused level of service. It covers the time-limited, lower-intensity treatment focusing on specific behaviors or deficits.
Modified TF – 52:
This modifier especially appends with 97153. It describes the reduced services. It is used in addition to modifier TF to signify further the level of focused behavior treatment technicians or healthcare professionals can render.
Frequently asked questions about 97153:
How is 97153 billed according to the units?
One unit of 97153 bills in 15 minutes, so 1 hour equals four units.
Who administers 97153?
Registered line technicians approved by the payer ( Registered Behaviour Technicians (RBTs), Relational Life Therapists (RLTs), or Board Certified Assistant Behaviour Analysts (BCBAs)) administer 97153.
What are some of the frequently used modifiers for 97153?
Some frequently used modifiers for 97153 are TG, TF, and TF- 52.
What therapy services are provided under this code?
This code provides direct 1:1 therapy. The services included are DTT (Discrete Trial Training), NET (Natural Environment Training) activities, task analysis, behavioral modification protocols, etc.
1. American Medical Association (AMA)
2. Centers for Medicare and Medicaid Services (CMS)
3. American Academy of Professional Coders (AAPC)
I am a licensed orthopedic manual physical therapist, certified mulligan practitioner and an AAPC registered certified professional coder with years of experience in writing medical content, including medical guidebooks, Articles and medical research for publication in international journals. Being a certified professional coder, I have been doing medical coding on all medical specialties since 2019.