97153 CPT Code Reimbursement Explained

The CPT code 97153 is an important code for behavioral health providers to understand. This code covers adaptive behavior treatment and reimbursement can vary depending on payer policies. Here are some key takeaways:

• 97153 is the CPT code for adaptive behavior treatment provided by a technician under the direction of a physician or qualified healthcare professional.
• It can be billed for direct treatment hours for behavioral interventions based on established protocols.
• 97153 should be billed in 15 minute increments and requires constant attendance.
• There are rules around using 97153 concurrently with other codes like 97155 and 97152.
• Reimbursement varies by payer but is often lower than for 97155. Understanding payer policies is key.

What is CPT Code 97153?

The Current Procedural Terminology (CPT) code 97153 covers adaptive behavior treatment with protocol modification requiring technician-level intervention. This code is used for behavioral interventions based on applied behavioral analysis (ABA) techniques.

Some key points on 97153:

• Used for direct treatment hours by a technician under the direction of a qualified provider
• Billed in 15 minute increments
• Requires constant attendance – treatment must be face-to-face
• Cannot be billed in the same session as 97155

How is 97153 Reimbursement Determined?

Reimbursement for 97153 varies by payer but is often lower than for code 97155. Some key considerations:

• Medicare reimbursement ranges from $12.71 – $16.94 per 15 minutes.
• Medicaid reimbursement varies significantly by state Medicaid plan.
• Commercial payers set their own rates but often reimburse less than Medicare.

It’s important to understand each payer’s policies to get full reimbursement for 97153. Confirm coverage and billing rules with each.

Can You Bill 97153 and 97155 Together?

No, 97153 and 97155 cannot be billed concurrently in the same session for the same patient.

• 97155 covers adaptive behavior treatment with protocol modification requiring a professional level of intervention.
• 97153 is used when treatment is provided by a technician under direction of a professional.

The two codes reflect different provider levels and cannot be billed in the same session.

Concurrent Billing with 97152

Code 97152 covers behavioral assessment and treatment planning. It involves administering tests and interpreting results to develop a treatment plan.

• 97152 is billed by the qualified healthcare professional.
• 97153 is billed by the technician providing direct treatment.

97152 and 97153 can be billed concurrently if performed by different providers – one doing assessment and planning, the other implementing the treatment plan.

Proper use of these codes is key to maximizing reimbursement for ABA services. Careful payer policy review helps ensure compliance and full payment.

Other Adaptive Behavior Treatment CPT Codes

Related adaptive behavior treatment codes include:

• 97154 for group adaptive behavior treatment
• 97151 for adaptive behavior treatment with protocol modification administered by physician or other qualified healthcare professional
• 97150 for adaptive behavior treatment by protocol

Using the right code for the service and provider level is critical for reimbursement.

Key Takeaways on 97153:

• Covers technician-level adaptive behavior treatment requiring protocol modification
• Billed in 15 minute increments
• Cannot be billed concurrently with 97155
• Reimbursement varies by payer but often lower than 97155
• Review payer policies and compliance rules
• Use with care alongside related codes like 97152, 97154, and 97151

Understanding the nuances of 97153 helps behavioral health providers maximize appropriate reimbursement and avoid payment delays or denials.