by Wyn Staheli, Director of Research
April 29th, 2016
Article Update: Effective January 1, 2019, several of the codes for these services were deleted and new CPT codes were assigned. Watch for payer policies regarding these code changes.
On July 1, 2014, 16 new codes (0359T-0374T) were added for reporting adaptive behavior assessments/interventions services. These codes were included with the mid-year release of CPT Category III codes
These new codes are included in the Reimbursement Guide for Behavioral Health. and may be used by any physician or other qualified licensed healthcare professional. According to the CPT Assistant (July 2014), typically these services are performed by "a behavior analyst (advanced degree professional) or licensed psychologist who designs and directs treatment protocols delivered by an assistant behavior analyst or technician(s). Some states require that behavior analysts be certified by the Behavior Analyst Certification Board® (BACB). State laws and government and private health plans determine coverage for these services and who may report and receive these services."
The June 2014 edition of CPT Assistant stated the following about these codes (emphasis added):
"The Category III codes for adaptive behavior assessment and treatment are applicable to patients of any age with autism spectrum disorders (ASDs) orother diagnoses or conditions (eg, developmental disabilities, head trauma) associated with deficient adaptive or maladaptive behaviors (eg, impaired social skills and communication, destructive behaviors, or additional functional limitations secondary to maladaptive behaviors). These codes were developed by a CPT Editorial Panel workgroup consisting of members representing psychiatry, psychology, speech-language and hearing, clinical social workers, neurology, occupational therapy, behavioral analysts, pediatrics, and payers."
It is important to note that payer coverage may vary. For example, some states have adopted the use of HCPCS codes (e.g., H2001, H2010, H2011, H2012, H2013, H2014, H2019, H2020) for adaptive behavior services, while others prefer CPT codes (90834, 90853, 96101, 96110, 96116, 96118, 96152, 92508, 97003). Therefore, it is essential to verify individual payer requirements. Also be aware of state professional licensing requirements.