Autism, a neurodevelopmental disorder, is a complex disability affecting 1 in 68 children.
It is now common for those diagnosed to follow a treatment plan. Some insurance policies require a treatment plan outlining the frequency and expected outcomes/goals for the services provided. State laws often require certain doctors, such as the patient’s medical doctor or psychologist, to complete the treatment plan. The patient’s progress is then measured and reported within the treatment plan as the patient is provided the necessary services.
At least 30 states have developed a form of mandate involving autism services in their exchange. Below is a link to the ABA’s state-by-state guide. This guide breaks down age requirements, annual reimbursement/coverage limitations, practitioner requirements, and much more.
Billing for autism services can seem daunting. The ABAI, APBI, Autism Speaks, and BACB have worked to create coding categories to help lessen the variation across all autistic billing services. In recent years, 15 new CPT codes were implemented. These codes are deemed the Category III Codes or T Codes. The purpose of the T codes is to encourage and enable uniformity in the reporting/billing of ABA Services. We have included a link to a helpful CPT crosswalk. The crosswalk includes assessment and treatment codes with descriptions, approved unit guidelines, who must be present for the services to be appropriately billed, etc.
https://www.autismspeaks.org/sites/default/files/docs/letter__crosswalk.pdf
Prior to the implementation of the T codes, there were numerous CPT codes used including H codes, 9 codes, and S codes. The CPT crosswalk provides a guide for which of the existing 9, H, and S codes are now enveloped under which T code.
Keep in mind, insurance companies have different requirements for authorizing and billing ABA services. Some payers will approve a blend of the HCPCS codes and T Codes/Category III CPT Codes for ABA services, but some payers have yet to incorporate the T Codes at all. It is important to know and follow the correct guidelines. Always verify with each patient’s insurance which codes are acceptable and approved per the prior authorization