Behavioral Health National Correct Coding Initiative (NCCI) Reminder for Applied Behavioral Therapy Claims
Date: 06/18/18
Last fall, Managed Health Services (MHS) notified Behavioral Health providers that NCCI editing would be activated for all Behavioral Health claims effective January 1, 2018.
NCCI applies to two types of edits:
- Procedure-to procedure edits (PTP) that define a pair of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits are to prevent improper payments when certain code combinations are reported. The combinations are sometimes allowed when billed with a modifier that indicates a distinct service.
- Medically Unlikely Edits (MUEs) define a maximum amount of units that may be billed for a HCPCS / CPT that would be reportable under most circumstances for a single date of service.
IHCP (Medicaid) Claims
Per the state guidance outlined in BT201705 and BR201626, ABA therapy services billed with CPT 96150-96155, a U1, U2 or U3 modifier in the first modifier field and an autism diagnosis are excluded from the MUE edits. This means that the daily unit edits are removed.
ABA therapy claims are not excluded from the PTP edits. In the chart below, the PTP edits for Medicaid claims are listed. If multiple services are approved via the prior authorization process and billed on the same day, the claim must include the appropriate modifier to indicate a distinctly different service was rendered.
MHS asks that providers use one of the following modifiers to describe the separate and distinct service:
- XE – Separate Encounter
- XP – Separate Practitioner
- XU – Unusual Separate Service
MHS will also accept modifier 59, but request that providers move toward the more descriptive modifiers as noted above.
Below is a representation of the codes listing for the CPT codes for ABA therapy. Only those code combinations that have a modifier indicator of 1 should be billed on the same DOS. A full listing of the Medicaid NCCI edits can be found at https://www.medicaid.gov/medicaid/program-integrity/ncci/edit-files/index.html
Column 1 | Column 2 | Effective Date of the Edit | Modifier indicator 0=not allowed 1=allowed 9 =not applicable | PTP Edit Rational |
96150 | 96151 | 20101001 | 0 | Mutually exclusive procedures |
96152 | 96151 | 20101001 | 1 | Mutually exclusive procedures |
96153 | 96151 | 20101001 | 1 | Mutually exclusive procedures |
96154 | 96151 | 20101001 | 1 | Mutually exclusive procedures |
96150 | 96152 | 20101001 | 1 | Mutually exclusive procedures |
96153 | 96152 | 20101001 | 0 | Mutually exclusive procedures |
96154 | 96152 | 20101001 | 1 | Mutually exclusive procedures |
96150 | 96154 | 20101001 | 1 | Mutually exclusive procedures |
96153 | 96154 | 20101001 | 0 | Mutually exclusive procedures |
Ambetter (Marketplace) Claims
Claims submitted for ABA therapy for Ambetter claims should be billed with the following ABA therapy codes.
CPT Code | Description |
0359T | Behavior identification assessment by the physician or other quaffed health care professional, face-to-face with patient and caregivers. Includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of results, discussion of findings and recommendations with the primary guardians/caregivers |
0360T | Observational behavioral follow-up assessment. Includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient. |
0361T | Observational behavioral follow-up assessment. each additional 30 minutes of technician time, face-to-face with the patient(list separately in addition to primary service code) |
0362T | Exposure behavioral follow-up assessment. Includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of time, face-to-face |
0363T | Exposure behavioral follow-up assessment, each additional 30 minutes of technician(s) time, face-to-face with the patient (list separately in addition to code for primary procedure) |
0364T | Adaptive behavior treatment by protocol administered by technician face-to-face with one patient; first 30 minutes of technician time |
0365T | Adaptive behavior treatment by protocol administered each additional 30 minutes (list separately in addition to primary procedure) |
0366T | Group adaptive behavior treatment by protocol administered by technician face-to-face with two or more patients; first 30 minutes of technician time |
0367T | Group adaptive behavior treatment by protocol each additional 30 minutes of technician time |
0368T | Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient. First 30 minutes of patient face-to-face |
0369T | Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient. Each additional 30 minutes of patient face-to-face |
0370T | Family adaptive behavior treatment guidance administered by physician or other qualified health care professional. |
0371T | Multiple -family group adaptive behavior treatment guidance administered by physician or other qualified professional |
0372T | Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients |
0373T | Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient |
0374T | Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes |
All NCCI Medicare edits for the Ambetter codes are being applied. For a complete listing of the MUE and PTP edits for ABA therapy service rendered please see: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html