Behavioral Analysis Treatment Codes
Autism Spectrum Disorder (ASD) is a developmental disability that can cause significant social, communication, and behavioral challenges. The differences in how ASD affects each person means that people with ASD have distinct strengths and challenges. Toward that end, treatment plans are usually multidisciplinary.
According to the CDC, the total costs per year for children with ASD in the United States were estimated to be between $11.5 billion – $60.9 billion (2011 US Dollars). On average, medical expenditures for children and adolescents with ASD were 4.1 – 6.2 times greater than those without ASD. ASD occurs in all racial, ethnic, and socioeconomic groups but is about 4 times more common among boys than among girls.
Applied Behavioral Analysis (ABA) is the behavioral treatment most commonly used with children with ASD. ABA is designed to help children improve his or her various functional skills, including, but not limited to, social skills, communication, daily living, controlling emotional responses, and develop positive behaviors.
Ten CPT / HCPCS procedure codes comprise and describe ABA therapy services. All ten procedure codes are times codes [15 minutes] with a medically unlikely edit value assigned by the CMS. Each procedure code outlines the type of service, whether the service occurred one-on-one or in a group setting, and if the service required the qualified health professional, a technician[s], or both.
Table 1: ABA therapy procedure codes and components for service, provider, and session types
What should your health plan consider as outlier utilization or unlikely ABA therapy?
- Providers and practice groups billing maximum or excessive services per day with potential service overlaps
- ABA therapy practice analysis to include assessment of staffing models
- Concurrent beneficiary treatments by other providers, i.e. occupational, physical, or speech therapy
- Providers and practice groups advertising assistance with homework and tutoring, on-site school support
- Patients whose ABA therapy service treatments exceed annual benefits
How can the Codoxo Forensic Platform assist your health plan with identifying emerging risks, trends, and outlier claims for ABA therapy services?
- The AI engine and detectors identify patterns, volume, and frequency across all peer groups and claims allowing customers to identify, analyze and respond to potential FWA and efficacy issues.
If you are an existing customer, please contact your Customer Success representative or firstname.lastname@example.org for assistance with this topic. If you would like more information or to setup a demonstration of the Codoxo Forensic Platform, please contact email@example.com.
VP of Customer Success