New CPT® Codes for Adaptive Behavior Services: What ABA Providers Need to Know

OVERVIEW WHAT ARE CPT CODES AND HOW ARE THEY DEVELOPED? ONCE A CPT CODE EXISTS, HOW IS IT VALUED? NEW ABA CODES FOR 2019 HOW TO PREPARE FOR THE NEW CODE IMPLEMENTATION

Background / Disclosures 9 years of coding and reimbursement experience with national medical specialty societies. Includes expertise in navigating the Medicare and Medicaid reimbursement cycles and other healthcare regulatory issues. MHCS conducts consulting services for the following organizations: Association for Behavior Analysis International Association of Professional Behavior Analysts Autism Speaks Behavior Analyst Certification Board Bierman ABA Autism Centers MBH Services LLC American Academy of Otolaryngology – Head and Neck Surgery Director of Operations for Residential Options, Inc.

What are CPT CODES? Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures. https://commerce.ama-assn.org/store/catalog The purpose of CPT is to provide uniform language that accurately describes healthcare services in order to foster consistent communication among physicans and other healthcare providers, patients, and third parties. CPT codes are issued, copyrighted, and maintained by the American Medical Association (AMA).

Who can request a new code? ESSENTIALLY ANYONE: Medical specialty societies, individual physicians, hospitals, third- party payers and other interested parties may submit for consideration by the panel. The AMA’s CPT staff reviews all requests to ensure they have not already addressed the question. If the application represents a new issue, the application is referred for evaluation and comment. An open comment period then follows which allows CPT Advisors and the “interested parties” from the public to submit comments and questions. Applicants are notified in advance if their CCA has not received any support and have the opportunity to withdraw.

CPT CYCLE: The Panel meets 3 times per year to review applications (winter, spring and fall). Applications are due approximately 2-3 months in advance of the CPT Editorial Panel meetings. This allows time for comment and review by the assigned Panel reviewers. Submitters receive comments in advance and have an opportunity to amend or withdraw based on those comments.

“I WIN, I WIN”!!! - Addition of a new code or revision of existing codes, in which case the change would appear in a forthcoming volume of CPT “MAYBE…” Referral to a workgroup for further study “TRY, TRY AGAIN” - Postponement to a future meeting (to allow submission of additional information in a new application) “SORRY, CHARLIE” - Rejection of the item

Types of CPT Codes CATEGORY I: These codes are numeric, and are five digits long. They are divided into six sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. These are permanent codes accepted by CMS and other third party payers. CATEGORY III: These codes are a set of temporary codes that allow data collection for emerging technology, services, and procedures. These codes are intended to be used for data collection to substantiate widespread usage.

Once I have a code, how is it valued? OPTIONS: Valuation through the AMA Relative Update Committee (RUC) process / survey Valuation through rulemaking (i.e. CMS assigns values and allows notice and comment of their proposed values) Remain “carrier priced”. CMS does not set a value and all payers determine their own reimbursement rates

WHAT IS THE AMA RUC? The RUC is a unique committee of representatives of major medical specialty societies. It is dedicated to describing the resources required to provide physician services, which CMS considers in developing Relative Value Units (RVUs) for health insurance billing codes.  The RUC does this through standardized surveys that are sent out by medical specialty societies or other professional organizations that are recognized as “stakeholders” by the AMA to members who are familiar with the services being valued. IMPORTANT NOTE: At present no behavior analysis organizations are recognized as stakeholders. Although the RUC provides recommendations, CMS makes all final decisions about Medicare/Medicaid payments. Those are released twice a year via the proposed Medicare Physician Fee Schedule (MPFS).

WHAT IS CARRIER PRICING? CPT codes are carrier priced when a RUC survey is not completed. This can occur for several reasons: The Specialty does not feel they can obtain an adequate sample (ranges from 30- 75), The Specialty does not have a seat on the necessary panels, and therefore, cannot sponsor a RUC survey, The Specialty elects not to survey and prefers the carrier priced valuation

WHAT IS CARRIER PRICING? How Does this Work? Specialties or individuals can inform CMS valuation by submitting valuation information/recommendations as part of the MPFS rulemaking cycle. If valuation information is not received, or CMS elects not to implement the recommendations, the codes can remain “carrier priced” Depending on the valuation outcome, commercial payers may or may not be likely to follow suit.

ABA Coding: Where we started Initial CCA submitted to the CPT Editorial Panel by the Association for Behavior Analysis International (ABAI) in May 2013 To address inconsistent coding and reimbursement for ABA services by payers The May 2013 meeting of the CPT Editorial Panel resulted in a workgroup being formed by to evaluate the needs for an ABA code set. Consisted of representatives from ABAI and organizations for other professions (psychology, speech- language pathology, occupational therapy, psychiatry, pediatrics, etc.)

ABA coding: Where we started October 2013 CPT Editorial Panel Meeting Multi-organization work group submitted a revised CCA. Category III (temporary) codes for “adaptive behavior services” were approved! Those codes took effect July 2014. ABAI conducted a survey of members to garner input. Feedback indicated that there were concerns with the code set.

ABA coding: Where we’ve been In 2015 an ABA Services Work Group was formed to develop a proposal to modify the Category III CPT codes and convert them to Category I codes Steering Committee: representatives of ABAI, the Association of Professional Behavior Analysts (APBA), the Behavior Analyst Certification Board (BACB), and Autism Speaks Work group: ABA providers (representing small, medium, and large practices or agencies), consumer advocates, and representatives of some health plans Sent a survey to 31,068 ABA providers to collect information on usage of the Category III and other codes Compiled other feedback on the Category III codes from hundreds of providers and payers Sought input from CPT Editorial Panel staff, professional societies identified by AMA as “stakeholders”

ABA Coding: Where we’ve been The ABA Workgroup Submitted a Code Change Application to CPT® Editorial Panel October 2016 and presented it at Panel’s February 2017 meeting The Application included: Revised code set Rationale for proposed revisions Vignettes and descriptions of work Evidence review Policy statements, guidelines from professional societies and payers Descriptions of providers

Key Concerns the CCA Aimed to Address Challenges with add on coding structure Challenges with 30 minute increments for codes Uncertainty about how to code/report “supervision” / Direction of technician work by BCBA Uncertainty about how to code/report indirect services / time Confusion about differences between group work and social skills groups Confusion about assessment coding strucutre. What does “exposure” mean?

ABA coding: Where we are Outcomes of the February 2017 CPT Editorial Panel meeting: 8 codes approved as Category I (97151 – 97158) 2 modified codes to remain Category III (0362T, 0373T) All other Category III codes for adaptive behavior services go away Effective January 1, 2019!!!

What does it mean to have Category I codes? Category III CPT codes are temporary and for new or emerging services, so some payers do not adopt them while others impose their own definitions and interpretations. signify only that there is some evidence of clinical efficacy and of “evolving clinical utilization” Category I CPT codes are permanent signify that the clinical efficacy of the services has been documented in research that meets rigorous AMA standards The services are performed by many physicians or other qualified healthcare professionals and are consistent with current medical practice

What does it mean to have Category I codes? For the 8 Category I codes for adaptive behavior services, there should be More uniform and consistent adherence to the descriptors as approved by the CPT Editorial Panel Fewer denials of coverage for ABA services on the false premise that they are “experimental,” “unproven,” or “not medically necessary.”

2019 ABA Codes: Assessment / Reassessment Codes Category I / III CPT® codes for adaptive behavior services 2019 Descriptor Code Time/units Attended by Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan 97151 per 15 minutes client, QHP3 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes 97152 client, technician (QHP3 may substitute for the technician) Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site4; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized to the patient’s behavior. 0362T client and 2 or more technicians; QHP3

2019 Category I ABA Codes: Treatment Codes Category I / III CPT® codes for adaptive behavior services 2019 Descriptor Code Time/units Attended by Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes 97153 per 15 minutes client, technician (QHP3 may substitute for the technician) Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes 97155 client, QHP3; may include technician and/or caregiver Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site4; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patient’s behavior. 0373T client and 2 or more technicians; QHP3 on site

2019 Category I ABA Codes: Group Codes Category I / III CPT® codes for adaptive behavior services 2019 Descriptor Code Time/units Attended by Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes 97154 per 15 minutes 2 or more clients, technician (QHP3 may substitute for technician) Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes 97158 2 or more clients & QHP3

2019 Category I ABA Codes: Family Codes Category I / III CPT® codes for adaptive behavior services 2019 Descriptor Code Time/units Attended by Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes 97156 per 15 minutes caregiver & QHP3 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes 97157 caregivers of 2 or more clients & QHP3

Some important differences between the 2014 Category III and 2019 Category I/III codes No add-on codes, so smaller code set (10 vs. 16) All codes are timed, in 15-min increments No code(s) for indirect services are allowed by CPT, but 97151 (behavior identification assessment by QHP) includes both face-to-face time with client to conduct assessments and time without client present to analyze and interpret assessment results and prepare initial treatment plan or progress report

Steering Committee Efforts Distribution of a coding crosswalk table showing how the new Category III codes were intended to be used. This is now updated to convert Cat III codes to Cat I 2019 code set. A survey was sent to over 31,068 ABA service agency administrators and practitioners to evaluate areas for improvement within the current code set. Countless responses to member/constituent inquiries Presentation of coding updates at annual conventions and numerous webinars Constituent distributions to provide updates on the process MUE edit letters to NCCI to rectify problematic coding caps Development of implementation resources to help providers navigate implementation and negotiation of contracts with their payers. Revision of the CPT® Assistant article on ABA codes to provide greater clarity on their intended use.

ABA Coding Resources: Development of a “Payer Packet” Payer packet (in production) Updated Coding Conversion Chart (released) Template letter to payers announcing release of new code set and requesting timelines / process for implementation (released Sept 18’) Valuation crosswalk tables to assist with payers who will require MPFS coding crosswalks with submitted claims – using comparisons to other “like” services’ relative value units (RVUs)to establish ABA code reimbursement Includes instructions and information on using comparator codes and relative value units (RVUs) for other similar services to establish reimbursement rates for 2019 adaptive behavior services codes

What you should do to prepare Educate payers Alert your payers about the new codes! Use the code conversion table and other resources from our Steering Committee to work with payers to achieve consistent use of the 2019 code set. If you haven’t already, give providers the BACB’s ASD treatment guidelines and APBA’s white paper “Identifying Applied Behavior Analysis Interventions” Obtain accurate MUEs for the new codes.

What you should do to prepare Review your contracts. Know your payer policies and requirements for medical necessity and coverage of ABA services as well as the terms for modification of your agreements. Compliance with contract provisions and payer requirements regarding claims documentation is essential, especially in light of recent billing fraud cases and heightened scrutiny of billing for ABA services. Ask questions! Engage a knowledgeable consultant or national organization to assist you in the transition (i.e. understanding the new codes, implementing them into your EMR, etc.) Prepare for disruption to revenue. It often takes payers about a quarter to update their EMRs after new codes are released on January 1, so prepare to weather the storm.

What you should do to prepare Calculate the value (rates) for your services. Consider all components of each service (overhead, practice expenses, technology, liability insurance, etc.) Include the services of both technicians and behavior analysts for codes that involve the work of both; don’t set a flat rate. Use the resources provided by our Steering Committee and other publicly available information, but take care to do that “homework” independently of other providers so as to comply with antitrust laws. Negotiate! It may not always seem like it, but rates in your contracts are always negotiable. Start early dialogue with payers!

Questions???