Prior Authorization for Applied Behavioral Analysis (ABA) CPT Codes

www.MercyCareAZ.org

October 1, 2019

Applicable to: Mercy Care Complete Care, Mercy Care RBHA, Mercy Care Long Term Care and Mercy Care DD

Effective November 1, 2019, a prior authorization will be required for Adaptive Behavior Treatments (CPT Codes 97153-97158). Adaptive Behavior Assessments (CPT Codes 97151 and 97152) will not require authorization. Service(s) rendered without authorization may be denied for payment. Please note those members who are transitioning to Mercy Care DD effective October 1, 2019 as part of the DDD contract implementation will not require authorization for 180 days post transition.

Effective November 1, 2019, providers delivering Applied Behavioral Analysis are to utilize the 2019 Category I/III CPT Codes for Adaptive Behavior Services. ABA codes and descriptions are outlined below.

Starting October 1, 2019, Mercy Care will start to accept authorizations for Adaptive Behavior Treatment (CPT Codes 97153-97158).

Following an Adaptive Behavioral Assessment, please complete the Standard Prior Authorization Request Form located on our website. Please be sure to list CPT codes with total number of units for the date span requested along with the start and end date of the service request. Please fax the Prior Authorization Request Form and the assessment to 800-217-9345.

Below are the new CPT Codes for 2019. Descriptions for these codes are as follows:

Adaptive Behavior Assessments (DO NOT REQUIRE AUTHORIZATION):

97151 - Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care 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.
97152 - Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.

Adaptive Behavior Treatments (REQUIRE PRIOR AUTHORIZATION):

97153 - Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
97154 - Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97155 - Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.
97156 - Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157 - Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158 - Group adaptive behavior treatment with protocol medication, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.

As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.

Thanks for all you do!