CPT® Code 97155 Requirements in the Autism Care Demonstration
Tuesday, June 27, 2023
Health Net Federal Services, LLC (HNFS) would like to remind applied behavior analysis (ABA) providers about the mandatory TRICARE Autism Care Demonstration (ACD) requirement for monthly adaptive behavior treatment with protocol modification encounters. Authorized ABA supervisors must render a minimum of one encounter per month (cannot be delegated to assistant behavior analysts) for Current Procedural Terminology (CPT®) 97155 for their patients enrolled in the ACD. If this requirement is not met, a claims penalty may apply.
Per TRICARE Operations Manual, Chapter 18, Section 4 guidelines, to meet minimum requirements, CPT code 97155 encounters must:
- Occur every month CPT code 97153 was billed.
- Have at least one encounter rendered by an authorized ABA supervisor (cannot be delegated to an assistant behavior analyst).
- Allot 15 minutes per unit.
Mandatory monthly CPT code 97155 encounters must not:
- Be a team or Individualized Education Program meeting.
- Be provided through telehealth.
- Exceed eight units per day.
Reimbursement Penalty
If the monthly CPT code 97155 encounter requirement has not been met, ABA claims submitted for the beneficiary’s entire six-month authorized treatment period will be subject to a 10% penalty. (Note: The 10% penalty may be waived if the ABA supervisor did not render CPT code 97153 services within the calendar month.)
For more information on ACD-related billing requirements, refer to TRICARE Operations Manual, Chapter 18, Section 4. We also offer details on our Billing page.
