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New codes for applied behavior analysis services begin in New Year

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New procedure codes for providers of applied behavior analysis, or ABA, services under the TRICARE Comprehensive Autism Care Demonstration take effect Jan.1. 

“There should be little to no impact on beneficiaries since reimbursement rates and services provided to beneficiaries will remain unchanged,” said Navy Capt. Edward Simmer, Chief Clinical Officer, TRICARE Health Plan, and a psychiatrist. 

"The implementation of the new codes improves the provider claims process and brings the autism care demonstration more in line with the TRICARE basic benefit," he said.

The ACD covers ABA services for all eligible TRICARE beneficiaries diagnosed with autism spectrum disorder.  Behavior Analysis is based on the science of learning and behavior. The goal of ABA services is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning. ABA providers use ABA techniques to help children diagnosed with autism reach their maximum potential.  

Current procedural terminology, or CPT, codes are the U.S. standard for how health care professionals document and report medical, surgical, radiology, laboratory, anesthesiology, and evaluation and management services. CPT codes are used by all providers, payers, and facilities. 

The Category III CPT codes currently in use for ABA services under the ACD will be replaced by Category I CPT codes on Jan. 1, mandated by the American Medical Association, which is responsible for the creation and implementation of CPT codes. This change applies to all funding sources and providers, including TRICARE.

Many of the Category I codes mirror the Category III codes, Simmer noted. However, all of the new codes will be timed in 15-minute increments. The existing codes were either not timed or were in 30-minute increments.

Also, the Category I codes don't provide a separate code for supervision of paraprofessional ABA providers, who often provide much of the “hands-on” ABA services, Simmer said. Under the existing codes, which have more flexibility than the new Category I codes, supervision was reimbursed by TRICARE under a modified definition of a temporary Category III code. The new Category I codes no longer provide this flexibility, eliminating the mechanism to reimburse for supervision independently. 

In light of this, TRICARE has also removed the TRICARE-specific requirements for the supervision of paraprofessional ABA providers by ABA supervisors. Supervision will no longer be a separate reimbursable service. However, paraprofessionals still will be supervised. Simmer said TRICARE will rely on the certifying and licensing bodies for behavior analysts, which require supervision as a core requirement for certification.

"Providers will continue to bill for services based on the certification level of the provider rendering care," he said, adding that this is the same as the current reimbursement system. 

"The change to supervision will give providers more flexibility with providing and receiving supervision and may free more provider time for direct services to new beneficiaries, which is expected to improve access to care,” Simmer said. “Quality should not suffer as the minimum supervision requirements are set by the certification body to ensure high quality care is delivered."

Information sessions for providers are scheduled for Dec. 19 and Jan. 9. For ACD announcements and invitations to future meetings, providers can subscribe to GovDelivery. Information for the provider meetings are sent with the meeting invites or can be requested at DHA.ACD@mail.mil. Providers may also contact the managed care support contractor for their region. 

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