APPLIED BEHAVIOR ANALYSIS (ABA) PROPOSED FEE SCHEDULE FOR MEDICAID FEE FOR SERVICE
PROPOSED CROSSWALK AND CODES FOR 2019
PROPOSED TO BE EFFECTIVE JANUARY 1, 2019
These additions as well as all prices on the fee schedule are subject to public comment, input, and suggestions until 30 day after posting on the HSD website. If any units or rates are changed based on the public comments, any
claims already paid will be adjusted as appropriate.
Notes on the fee schedule:
1. This proposed fee schedule does not represent any increases or decreases from the current rates. However, it does show additions for the modifier U9
which represents a practitioner new to the fee schedule, a Board Certified Assistant Behavioral Analyst. Also, the use of modifier U2 to distinguish between a
Behavior Technician with a bachelor's degree and without a bachelor's degree will no longer be used. Modifier U1 will be used to identify both levels of Behavior Technicians
practitioners.
2. Nothing on the fee schedule is to be interpreted as an exemption from any board license requirements or supervisory requirements.
3. FQHC's, Indian Health Service, PL 638 Tribal Healthcare Providers, other state agencies, other governmental units, hospital outpatient facilities, may also
be authorized to perform some services.
4. This fee schedule is for services provided to Medicaid fee for service recipients. Managed care provider rates are determined between the provider and
the MCO and may differ from the fee-for-service fee schedule. These rates also are not applicable to claims paid by the HSD Behavioral Health Services
Division.
1
AEP
BA
BCBA-D
BCBA
BCaBA or BAA
BT
CDE
ISP
Qualifying Psychologist
Supervising BAA
Amount
mod 1 mod 2
New Comprehensive Diagnostic Eval (CDE) T1026 TG 130.00$
Development of Integrated Service Plan (ISP) - Initial -
following a CDE
T1026 TG HI 130.00$
ISP Update T1026 HK HI 130.00$
CDE to be performed every 36 months or sooner, if medically
warranted.
Modifiers
Behavior Analyst Certification Board (BACB®) - Board Certified Assistant Behavior Analyst (also referred to as a Behavior Assistant Analyst - BAA)
Behavior Technician - a group term which includes: A bachelor's or non-bachelor's degree BACB® - Registered Behavior Technician (RBT); a Behavioral Intervention
Certification Council (BICC®) - Board Certified Autism Technician (BCAT®); or a non-certified behavior technician completing his or her RBT or BCAT certification (time
limited)
A New Mexico Regulation and Licensing Department Psychologist Examiners Board licensed psychologist who is also certified by the American Board of Professional
Psychology in Behavioral and Cognitive Psychologist who was tested in ABA.
Behavior Assistant Analyst (BAA) whose BACB approved contract with his or her approved BA supervisor allows for the BAA to supervise a Behavior Technician (BT)
Behavior Analyst - a group term which includes: a Qualifying Psychologist, a BCBA-D or a BCBA
Integrated Service Plan
NOTES
Mental health assessment
1 Unit = 1 hour
Maximum of 10 one hour units per CDE
Prior Auth: NO
Qualifying practitioners: AEP
Code
DETAILED SERVICE
Description
Autism Evaluation Practitioner - An AEP is the ABA STAGE 1 Autism Evaluation Practitioner.
Must be a licensed psychologist, or board-certified or board-eligible physician in developmental behavioral pediatrics, pediatric neurology, or child psychiatry; and have
experience in, or knowledge of, the medically necessary applications of ABA and other empirically supported intervention techniques; be qualified to conduct and
document a Comprehensive Diagnostic Evaluation, a Targeted Evaluation, and a Targeted Risk Evaluation for the purposes of developing an Integrated Service Plan; and
have advanced training and clinical experience in the diagnosis and treatment of ASD and related neurodevelopmental disorders, including knowledge about typical and
atypical child development; and experience with variability within the ASD population; and have advance training in differential diagnosis of ASD from other
developmental, psychiatric, and medical disorders.
Behavior Analyst Certification Board (BACB®) - Board Certified Behavior Analyst - Doctorate
Behavior Analyst Certification Board (BACB®) - Board Certified Behavior Analyst
Comprehensive Diagnostic Evaluation used to determine if a recipient can be appropriately diagnosed with ASD or with a different diagnosis.
ABA STAGE 1 - CDE, TARGETED EVALUATION and TARGETED RISK EVALUATION, and INTEGRATED SERVICE PLAN
No change for
2019
Change
2
Amount
mod 1 mod 2
Targeted Evaluation or Risk Evaluation T1026 HK 130.00$
Development of ISP - following a Targeted Evaluation
or Risk Evaluation
T1026 TG HI 130.00$
ISP Update - following a Targeted Evaluation or Risk
Evaluation
T1026 HK HI 130.00$
Amount
mod 1 mod 2
Qualifying Psychologist 97151 U5 $82.50
BCBA-D 97151 U4 $82.50
BCBA 97151 U3 $70.75
Qualifying Psychologist 0359T U5
$ 330.00
BCBA-D 0359T U4
$ 330.00
BCBA 0359T U3
$ 283.00
A Targeted Evaluation is performed after a CDE is completed.
Use the Targeted Evaluation when aspects of the recipient's
presentation change.
When aspects of the current ISP require updating without a new
type of evaluation (CDE or Targeted Evaluation) being
completed, use the ISP Update.
There are no longer separate codes for updating a Targeted Risk
Evaluation or the ISP following the Targeted Risk Evaluation.
The AEP determines if the changes in the patient's presentation
warrants a revised CDE.
Modifiers
Description
Allowed Practitioners
Code
Mental health assessment - for a
Targeted Evaluation or a Risk Evaluation
(formerly listed as Treatment Plan
Development, ISP)
1 Unit = 1 hour
Prior Auth: NO
Qualifying practitioners: AEP
The assessment is the gathering from data, interviews,
observations that is then incorporated into a Behavior or
Functional Analytic Assessment report and an ABA Stage 3
Treatment Plan .
To be done annually or sooner, if medically warranted.
NOTES
0359T is no
longer valid for
dates of
service after
12/31/2018
Behavior or Functional Analytic
Assessment
1 unit = 1 Assessment
Prior Auth: NO
Behavior Identification Assessment
(described as Behavior or Functional
Analytic Assessment in program rules)
1 unit = 15 minutes (new units for 2019)
Prior Auth: NO
The new proposed rate is the 2018 rate (per service) divided by
4 (to pay for every 15 minutes.)
The assessment is the gathering from data, interviews,
observations that is then incorporated into a Behavior or
Functional Analytic Assessment report and an ABA Stage 3
Treatment Plan .
To be done annually or sooner, if medically warranted.
NOTES
97151 replaces
0359T for 2019
Units have
changed
ABA STAGE 2 - BEHAVIOR OR FUNCTIONAL ANALYTIC ASSESSMENT AND DEVELOPMENT OF TREATMENT PLAN
No change for
2019 other
than
combining the
evaluations
together on
the fee
schedule
instead of
listing them
separately
Change
Change
Description
DETAILED SERVICE
Code
Modifiers
3
Amount
mod 1 mod 2
Qualifying Psychologist 97152 U5
$ 41.25
BCBA-D 97152 U4
$ 41.25
BCBA 97152 U3
$ 36.75
Qualifying Psychologist 0360T U5
$ 82.50
BCBA-D 0360T U4
$ 82.50
BCBA 0360T U3
$ 73.50
Qualifying Psychologist 0361T U5
$ 82.50
BCBA-D 0361T U4
$ 82.50
BCBA 0361T U3
$ 73.50
NEW FOR 2019
Qualifying Psychologist 0362T U5
$ 50.00
BCBA-D 0362T U4
$ 50.00
BCBA 0362T U3
$ 50.00
Behavior or Functional Analytic
Assessment Follow-up (1st 30 minutes)
1 unit = Initial 30 minutes
Prior Auth: NO
Behavior or Functional Analytic
Assessment Follow-up (each additional
30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: NO
Behavior Identification Supporting
Assessment - refer to CPT description for
required providers (formerly Exposure
Behavioral Follow-up Assessment BAA or
BT)
1 unit = 15 min(new units for 2019)
Prior Auth: NO
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.)
This code is typically used for recipients that have more specific
severe destructive behaviors and are assessed using structured
testing to examine events, cues, responses, and associated
consequences. Otherwise, code 97151 or 97152 may be more
appropriate. Refer to CPT description for required providers.
Code is used when the assessment is conducted over more than
one day and is to be billed for each date the assessment follow-
up service is rendered.
0360T is no
longer valid for
dates of
service after
12/31/2018
0361T is no
longer valid for
dates of
service after
12/31/2018
0362T remains
valid for 2019
but with new
units with an
expanded
description
Allowed Practitioners
Code
Modifiers
NOTES
This is an ADD-ON code and can only be billed when 0360T is
billed on the same date of service.
Description
Behavior Identification Supporting
Assessment (described as Behavior or
Functional Analytic Assessment Follow
Up in program rules)
1 unit = 15 minutes (new units for 2019)
Prior Auth: NO
97152 replaces
0360T and
0361T for 2019
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.)
Note that there is no longer different codes for the initial time
and the additional time. The rate is just per 15 minutes of
service.
The code is used when the assessment is conducted over more
than one day and is to be billed for each date the assessment
follow-up service is rendered.
Change
4
Qualifying Psychologist
0362T U5
$ 100.00
BCBA-D 0362T U4
$ 100.00
BCBA 0362T U3
$ 100.00
Qualifying Psychologist 0363T U5
$ 100.00
BCBA-D
0363T U4
$ 100.00
BCBA 0363T U3
$ 100.00
Exposure Behavioral Follow-up
Assessment BAA or BT (each additional
30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: NO
This is an ADD-ON code and can only be billed when 0362T is
billed for the same date of service.
0363T is no
longer valid for
dates of
service after
12/31/2018
0362T remains
valid for 2019
but with new
units with an
expanded
description
Exposure Behavioral Follow-up
Assessment BAA or BT (initial 30
minutes)
1 unit = Initial 30 minutes
Prior Auth: NO
This code is typically used for recipients that have more specific
severe destructive behaviors and are assessed using structured
testing to examine events, cues, responses, and associated
consequences. Otherwise, code 0359T may be more
appropriate. Refer to CPT description for required providers.
5
Amount
mod 1 mod 2
Qualifying Psychologist T1026 U5 UC
$ 70.00
BCBA-D T1026 U4 UC
$ 70.00
BCBA T1026 U3 UC
$ 70.00
Qualifying Psychologist T1026 U5 UD
$ 90.00
BCBA-D T1026 U4 UD
$ 90.00
BCBA T1026 U3 UD
$ 90.00
BCaBA (Supervising) T1026 U9 UD
$ 81.00 This code is being newly added to the ABA fee schedule.
Modifiers
ABA Direct and Indirect Case Supervision
(modifier UD)
1 unit = 1 Service
Prior Auth: YES
At least 1 hour of case supervision is to
be performed for every 10 hours of
STAGE 3 services. More than 2 hours of
case supervision per 10 hours of STAGE 3
services requires prior authorization to,
not as a program limit, but, rather, to
assure medical necessity.
Description
Allowed Practitioners
Code
NOTES
If a full 60 minutes is not provided in one day, bill a partial unit
using decimal points. When the session continues on a different
day, the time spent on that day is also billed using the decimal
point as appropriate to account for the full hour. The full hour
of service does not need to be provided in a single day.
If more than one session is required, the additional session is
not required to be on the same date of service, but must be
specific to the units of service that the first session covers.
If a full 60 minutes is not provided in one day, bill a partial unit
using decimal points. When the session continues on a different
day, the time spent on that day is also billed using the decimal
point as appropriate to account for the full hour. The full hour
of service does not need to be provided in a single day.
ABA Clinical Management (modifier UC)
1 unit = 1 Hour session
Prior Auth: YES
At least 1 hour of clinical management is
to be performed for every 10 hours of
STAGE 3 services. More than 2 hours of
clinical management per 10 hours of
Stage 3 services requires prior
authorization, not as a program limit,
but, rather, to assure medical necessity.
ABA STAGE 3 - IMPLEMENTATION OF TREATMENT PLAN
Change
No change for
2019
No change for
2019
6
Amount
mod 1 mod 2
Qualifying Psychologist 97153 U5
$ 15.00
BCBA-D 97153 U4
$ 15.00
BCBA 97153 U3
$ 14.00
BCaBA 97153 U9
$ 12.50
BT (with or without bachelor's degree) 97153 U1
$ 12.50
Qualifying Psychologist 0364T U5
$ 30.00
BCBA-D 0364T U4
$ 30.00
BCBA 0364T U3
$ 28.00
BCaBA 0364T U9
$ 25.00
BT (with or without bachelor's degree) 0364T U1
$ 25.00
Qualifying Psychologist 0365T U5
$ 30.00
BCBA-D 0365T U4
$ 30.00
BCBA 0365T U3
$ 28.00
BCaBA 0365T U9
$ 25.00
BT with/or without bachelor's degree
0365T
U1
$ 25.00
Additional time following 0364T taking place on the same day.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
Adaptive Behavior Treatment by
Protocol, with 1 recipient (each
additional 30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: YES
Use this code for the first 30 minutes of service for the day.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
Adaptive Behavior Treatment by
Protocol, with 1 recipient (1st 30
minutes)
1 unit = Initial 1st 30 minutes
Prior Auth: YES
Adaptive Behavior Treatment by
Protocol
1 unit = 15 min (new units for 2019)
Prior Auth: YES
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.) Note that there are no
longer different codes for the initial time vs. the add-on
additional time. The rate is just per 15 minutes of service.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
Allowed Practitioners
Code
Modifiers
NOTES
0364T is no
longer valid for
dates of
service after
12/31/2018
0365T is no
longer valid for
dates of
service after
12/31/2018
97153 replaces
0364T and
0365T for 2019
Change
Description
7
Qualifying Psychologist 97154 U5 UA
$ 8.50
BCBA-D 97154 U4 UA
$ 8.50
BCBA 97154 U3 UA
$ 8.00
BCaBA 97154 U9 UA
$ 7.25
BT (with or without bachelor's degree) 97154 U1 UA
$ 7.25
Qualifying Psychologist 0366T U5 UA
$ 17.00
BCBA-D 0366T U4 UA
$ 17.00
BCBA 0366T U3 UA
$ 16.00
BCaBA 0366T U9 UA
$ 14.50
BT (with or without bachelor's degree) 0366T U1 UA
$ 14.50
Qualifying Psychologist 0367T U5 UA
$ 17.00
BCBA-D 0367T U4 UA
$ 17.00
BCBA 0367T U3 UA
$ 16.00
BCaBA 0367T U9 UA
$ 14.50
BT (with or without bachelor's degree) 0367T U1 UA
$ 14.50
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.) Note that there are no
longer different codes for the initial time vs. the add-on
additional time. The rate is just per 15 minutes of service.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
Group Adaptive Behavior Treatment by
Protocol, with 2 to 4 Recipients (each
additional 30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: YES
Group Adaptive Behavior Treatment by
Protocol, with 2 to 4 recipients
Note the modifier UA is used to identify
this size of group
In considering the number in the group,
include both Medicaid and non-Medicaid
recipients
1 unit = 15 min (new units for 2019)
Prior Auth: YES
Additional time following 0366T taking place on the same day.
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
97154 replaces
0366T and
0367T for 2019
(Note the
modifier UA is
used for this
size of group)
0366T is no
longer valid for
dates of
service after
12/31/2018
0367T is no
longer valid for
dates of
service after
12/31/2018
Group Adaptive Behavior Treatment by
Protocol, with 2 to 4 recipients (1st 30
minutes)
1 unit = Initial 30 minutes
Prior Auth: YES
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
Use this code for the first 30 minutes of service for the day.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
8
Qualifying Psychologist 97154 U5 UB
$ 4.25
BCBA-D 97154 U4 UB
$ 4.25
BCBA 97154 U3 UB
$ 4.25
BCaBA 97154 U9 UB
$ 3.63
BT (with or without bachelor's degree) 97154 U1 UB
$ 3.63
Qualifying Psychologist 0366T U5 UB
$ 8.50
BCBA-D 0366T U4 UB
$ 8.50
BCBA 0366T U3 UB
$ 8.00
BCaBA 0366T U9 UB
$ 7.25
BT (with or without bachelor's degree) 0366T U1 UB
$ 7.25
Qualifying Psychologist 0367T U5 UB
$ 8.50
BCBA-D 0367T U4 UB
$ 8.50
BCBA 0367T U3 UB
$ 8.00
BCaBA 0367T U9 UB
$ 7.25
BT (with or without bachelor's degree) 0367T U1 UB
$ 7.25
Group Adaptive Behavior Treatment by
Protocol, with 5 to 8 recipients (1st 30
minutes)
1 unit = Initial 30 minutes
Prior Auth: YES
Group Adaptive Behavior Treatment by
Protocol, with 5 to 8 recipients (each
additional 30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: YES
Group Adaptive Behavior Treatment by
Protocol, with 5 to 8 recipients
Note the modifier UB is used to identify
this size of group
In considering the number in the group,
include both Medicaid and non-Medicaid
recipients
1 unit = 15 min (new units for 2019)
Prior Auth: YES
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.) Note that there is no longer
different codes for the initial time and the additional time. The
rate is just per 15 minutes of service.
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
97154 replaces
0366T and
0367T for 2019
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
Use this code for the first 30 minutes of service for the day.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
0366T is no
longer valid for
dates of
service after
12/31/2018
0367T is no
longer valid for
dates of
service after
12/31/2018
Additional time following 0366T taking place on the same day.
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
The modifier U9 and price is being newly added to the ABA fee
schedule. The U2 modifier is not longer on the fee schedule as
the U1 modifier will serve for both the bachelor's and without
bachelor's level practitioner.
9
Amount
mod 1 mod 2
Qualifying Psychologist 97155 U5
$ 35.00
BCBA-D 97155 U4
$ 35.00
BCBA 97155 U3
$ 25.00
Qualifying Psychologist 0368T U5
$ 70.00
BCBA-D 0368T U4
$ 70.00
BCBA 0368T U3
$ 50.00
Qualifying Psychologist 0369T U5
$ 70.00
BCBA-D 0369T U4
$ 70.00
BCBA 0369T U3
$ 50.00
Adaptive Behavior Treatment by
Protocol Modification with 1 recipient
(1st 30 minutes)
1 unit = 1 Initial 30 minutes
Prior Auth: YES
Adaptive Behavior Treatment with
Protocol Modification, with 1 recipient
(each additional 30 minutes)
1 unit = Each additional 30 minutes
Prior Auth: YES
Description
Allowed Practitioners
Code
Modifiers
NOTES
Changes
Adaptive Behavior Treatment by
Protocol Modification with 1 recipient
1 unit = 15 min (new units for 2019
Prior Auth: YES
The new proposed rate is the 2018 rate (per 30 minutes) divided
by 2 (to pay for every 15 minutes.)
Note that there is no longer different codes for the initial time
and the additional time. The rate is just per 15 minutes of
service.
This code allows the BA, while rendering the ABA Treatment
Plan, to modify the plan with the recipient present (as
compared to updating the ABA Treatment Plan without the
recipient present.)
97155 replaces
0368T and
0369T
0368T is no
longer valid for
dates of
service after
December 31,
2018.
0369T is no
longer valid for
dates of
service after
December 31,
2018.
This code allows the BA, while rendering the ABA Treatment
Plan, to modify the plan with the recipient present (as
compared to updating the ABA Treatment Plan without the
recipient present.)
10
Amount
mod 1 mod 2
Qualifying Psychologist 97156 U5
$ 22.55
BCBA-D 97156 U4
$ 22.55
BCBA 97156 U3
$ 16.25
Qualifying Psychologist 0370T U5
$ 90.00
BCBA-D 0370T U4
$ 90.00
BCBA 0370T U3
$ 65.00
mod 1 mod 2
Qualifying Psychologist 97157 U5
$ 45.00
BCBA-D 97157 U4
$ 45.00
BCBA 97157 U3
$ 32.50
Qualifying Psychologist 0371T U5
$ 45.00
BCBA-D 0371T U4
$ 45.00
BCBA 0371T U3
$ 32.50
Multi Family Group Adaptive Behavior
Treatment Guidance without the
Recipient Present
1 unit = Per session
Prior Auth: YES
Family Adaptive Behavior Treatment
Guidance without the Recipient Present
1 unit = 15 min (new units for 2019)
Prior Auth: YES
NOTES
I unit billed encompasses the entire group regardless of the
number present
Changes
Description
Allowed Practitioners
Code
Modifiers
Family Adaptive Behavior Treatment
Guidance without the Recipient Present
1 unit = Per session
Prior Auth: YES
1 unit billed encompasses the entire group regardless of the
number present.
Multi Family Group Adaptive Behavior
Treatment Guidance without the
Recipient Present
1 unit = 15 min (new units for 2019)
Prior Auth: YES
NOTES
The new proposed rate is the 2018 rate (per service) divided by
2 (to pay for every 15 minutes.)
1 unit billed encompasses the entire group regardless of the
number present.
Modifiers
Changes
Description
Allowed Practitioners
Code
Amount
0371T is no
longer valid for
dates of
service after
December 31,
2018.
97157 replaces
0371T
97156 replaces
0370T
0370T is no
longer valid for
dates of
service after
December 31,
2018.
The new proposed rate is the 2018 rate (per service) divided by
4 (to pay for every 15 minutes.)
1 unit billed encompasses the entire group regardless of the
number present.
11
Amount
mod 1 mod 2
Qualifying Psychologist 97158 U5 UA
$ 10.00
BCBA-D 97158 U4 UA
$ 10.00
BCBA 97158 U3 UA
$ 8.00
Qualifying Psychologist 0372T U5 UA
$ 40.00
BCBA-D 0372T U4 UA
$ 40.00
BCBA 0372T U3 UA
$ 32.00
Qualifying Psychologist 97158 U5 UB
$ 5.00
BCBA-D 97158 U4 UB
$ 5.00
BCBA 97158 U3 UB
$ 4.00
Qualifying Psychologist 0372T U5 UB
$ 20.00
BCBA-D 0372T U4 UB
$ 20.00
BCBA 0372T U3 UB
$ 16.00
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
Adaptive Behavior Treatment Social Skill
Group with 2 to 4 Recipients
Note the modifier UA is used to identify
this size of group
In considering the number in the group,
include both Medicaid and non-Medicaid
recipients.
1 unit = 15 min (new units for 2019)
Prior Auth: YES
Adaptive Behavior Treatment Social Skill
Group with 5 to 8 Recipients
1 unit = Per session
Prior Auth: YES
Description
The new proposed rate is the 2018 rate (per service) divided by
4 (to pay for every 15 minutes.)
1 unit billed encompasses the entire group regardless of the
number present.
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
97158 replaces
0372T
Adaptive Behavior Treatment Social Skill
Group with 2 to 4 Recipients
1 unit = per session
Prior Auth: YES
In considering the number in the group, include both Medicaid
and non-Medicaid recipients.
97158 replaces
0372T
0372T is no
longer valid for
dates of
service after
December 31,
2018.
0372T is no
longer valid for
dates of
service after
December 31,
2018.
Adaptive Behavior Treatment Social Skill
Group with 5 to 8 Recipients
1 unit = Per session
In considering the number in the group,
include both Medicaid and non-Medicaid
recipients.
The new proposed rate is the 2018 rate (per service) divided by
4 (to pay for every 15 minutes.)
1 unit billed encompasses the entire group regardless of the
number present.
Changes
Allowed Practitioners
Code
Modifiers
NOTES
12
mod 1 mod 2
Qualifying Psychologist 0373T U5
$ 75.00
BCBA-D 0373T U4
$ 75.00
BCBA 0373T U3
$ 67.50
Qualifying Psychologist 0373T U5
$ 300.00
BCBA-D 0373T U4
$ 300.00
BCBA 0373T U3
$ 270.00
Qualifying Psychologist 0374T U5
$ 150.00
BCBA-D 0374T U4
$ 150.00
BCBA 0374T U3
$ 135.00
Modifiers
Adaptive Behavior Treatment with
Protocol Modification , requiring 2 or
more BTs, BAAs, other BAs or
Combinations (each additional 30
minutes)
1 unit = Each additional 30 minutes
Prior Auth: YES
For Specialty Care: Adaptive Behavior
Treatment with Protocol Modification,
requiring 2 or more BTs, BAAs, other BAs
or Combinations
1 unit = 15 minutes
Prior Auth: YES
Description
NOTES
The proposed payment The new proposed rate is the 2018 rate
(60 minutes) divided by 4 ( to pay for every 15 minutes.)
The code billed at one unit includes all the BTs, BAAs, and BAs in
combination. The Specialty Care Practitioner is the only
individual who bills for the service. Refer to CPT description for
provider and service requirements.
Allowed Practitioners
Code
0374T is no
longer valid for
dates of
service after
December 31,
2018.
Use 0373T
instead.
0373T remains
valid for 2019
with an
expanded
description
0373T remains
valid for 2019
but with new
units with an
expanded
description. It
also replaces
0374T
Adaptive Behavior Treatment with
Protocol Modification, requiring 2 or
more BTs, BAAs, other BAs or
Combinations (1st 60 minutes)
1 unit = Initial 60 minutes
Prior Auth: YES
Use this code for the first hour of service for the day. If a full 60
minutes is not provided in one day, bill a partial unit using
decimal points.
The code billed at one unit includes all the BTs, BAAs, and BAs in
combination. The Specialty Care Practitioner is the only
individual who bills for the service.
Changes
Amount
ABA STAGE 3 - SPECIALTY CARE
13