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ABA Billing & CPT Codes: Complete 2026 Guide for BCBAs and Practice Owners

Index​

ABA billing complexity catches many practitioners off guard. The difference between billing 97153 versus 97155, or selecting the correct modifier, can mean the difference between reimbursement and denial. Yet most BCBAs receive minimal training on billing during their certification process—we're taught clinical skills, not revenue cycle management.

The stakes are high. Billing errors contribute to claim denials, audit flags, and compliance violations that can jeopardize your practice's financial health and professional standing. Understanding ABA CPT codes isn't just about getting paid—it's about accurate representation of the services you provide and maintaining the integrity of your clinical documentation.

This guide provides a comprehensive breakdown of ABA billing codes, from the nuances of 97153 vs. 97155 to modifier requirements and common denial reasons. Whether you're a BCBA submitting your first claims, a practice owner troubleshooting high denial rates, or a billing specialist new to ABA, you'll find the technical details and practical guidance you need.

Streamline Your ABA Billing Documentation

Billing accuracy starts with documentation. When session notes, authorization forms, and treatment plans align with CPT code requirements, denials decrease dramatically. Instafill.ai helps ABA practices auto-populate CPT codes and service details across documentation, ensuring consistency between clinical records and billing claims. See how Headstart Health achieved 99%+ accuracy on their authorization forms.

Understanding ABA CPT Codes​

Current Procedural Terminology (CPT) codes are standardized numeric codes used to describe medical services for billing purposes. ABA-specific CPT codes were introduced in 2019, replacing the previous Category III codes and creating a dedicated coding structure for applied behavior analysis services.

The ABA CPT Code Family​

ABA services primarily use codes in the 97151-97158 range:

CodeDescriptionWho Can BillTime Unit
97151Behavior identification assessmentBCBA, Psychologist15 minutes
97152Behavior identification supporting assessmentRBT, BCaBA under BCBA supervision15 minutes
97153Adaptive behavior treatment by protocol (1:1)RBT, BCaBA, BCBA15 minutes
97154Group adaptive behavior treatment by protocolRBT, BCaBA under BCBA supervision15 minutes
97155Adaptive behavior treatment with protocol modificationBCBA15 minutes
97156Family/caregiver trainingBCBA15 minutes
97157Group adaptive behavior treatment (BCBA-delivered)BCBA15 minutes
97158Group treatment with protocol modificationBCBA15 minutes

Time-Based Billing Fundamentals​

ABA CPT codes are time-based, billed in 15-minute increments (units). Understanding unit calculation is essential for accurate billing:

Standard calculation:

  • 1 unit = 15 minutes
  • 4 units = 60 minutes (1 hour)
  • 8 units = 120 minutes (2 hours)

The 8-minute rule (Medicare and many commercial payers):

Service DurationUnits to BillNotes
8-22 minutes1 unitMinimum billable threshold
23-37 minutes2 units
38-52 minutes3 units
53-67 minutes4 units1-hour equivalent
68-82 minutes5 units
83-97 minutes6 units
98-112 minutes7 units
113-127 minutes8 units2-hour equivalent

Your documented session time must support the units billed. A session documented as 50 minutes cannot be billed as 4 units (60 minutes).

Code 97151: Behavior Identification Assessment​

Description: Comprehensive assessment procedures conducted by a qualified healthcare provider (BCBA or licensed psychologist) to identify behavioral targets, develop function hypotheses, and create treatment recommendations.

When to Use 97151​

Bill 97151 when conducting:

  • Initial comprehensive assessments (intake evaluations)
  • Functional Behavior Assessments (FBAs)
  • Skills assessments using standardized tools (VB-MAPP, ABLLS-R, Vineland)
  • Reassessments for treatment plan updates
  • Assessment interpretation and treatment planning

Documentation Requirements​

To support 97151 billing, documentation must include:

Assessment procedures conducted:

  • Name of standardized assessment tools administered
  • Interview procedures (with whom, duration)
  • Observation methods (direct observation, ABC data collection)
  • Record review activities

Time documentation:

  • Start and end times for each assessment component
  • Total face-to-face assessment time
  • Time spent in non-face-to-face activities (scoring, interpretation)

Clinical findings:

  • Assessment results with scores/levels
  • Identified skill deficits
  • Behavior function hypotheses
  • Treatment recommendations

Billing Limits and Considerations​

Initial assessments: Most payers authorize up to 8 units (2 hours) for initial comprehensive assessments

Reassessments: Typically limited to 6 units per authorization period (every 6 months)

Payer variations: Some payers require separate authorization for assessment units; others include assessment within total authorized hours

97151 vs. 97152​

97152 (Behavior identification supporting assessment) is used when technicians or assistant behavior analysts conduct portions of the assessment under BCBA supervision—such as administering standardized assessments or collecting observational data. The BCBA bills 97151 for the interpretation, synthesis, and treatment planning components.

Example billing split:

  • RBT administers ABLLS-R under BCBA direction: 97152 (4 units)
  • BCBA interprets results, writes assessment report, develops treatment plan: 97151 (4 units)

Code 97152: Behavior Identification Supporting Assessment​

Description: Assessment activities conducted by a technician (RBT) or assistant behavior analyst (BCaBA) under the direction of a qualified healthcare provider (BCBA). This code captures the technician-administered portions of comprehensive assessments.

When to Use 97152​

Bill 97152 when technicians or BCaBAs:

  • Administer standardized assessment tools (VB-MAPP, ABLLS-R, AFLS, PEAK)
  • Conduct structured direct observations
  • Collect ABC (Antecedent-Behavior-Consequence) data
  • Complete preference assessments
  • Gather baseline data on target behaviors
  • Conduct caregiver/teacher interviews under BCBA direction

Key requirement: The technician must be working under the direct supervision and direction of a BCBA. The BCBA provides the assessment protocol and oversees the process, while the technician implements it.

Who Can Bill 97152​

  • RBTs: Under direct supervision of BCBA
  • BCaBAs: Under supervision of BCBA
  • Other qualified technicians: As defined by payer credentialing requirements

Documentation Requirements​

97152 documentation must include:

Assessment activities:

  • Specific assessment tools or protocols administered
  • Name of supervising BCBA who directed the assessment
  • Assessment environment and conditions
  • Duration of each assessment component

Data collected:

  • Raw scores or frequencies recorded
  • Observation notes
  • Interview responses (if applicable)

Example compliant note: "Administered VB-MAPP Milestones Assessment (Levels 1-2) per BCBA direction. Assessment conducted in clinic therapy room. Completed mand, tact, listener responding, and visual perceptual/match-to-sample domains. Total assessment time: 90 minutes. Raw data recorded on standardized scoring form for BCBA interpretation. Supervising BCBA: Jane Smith, BCBA."

97152 Billing Considerations​

Relationship to 97151: 97152 is the technician counterpart to 97151. When both codes are used for the same assessment:

  • Technician administers assessment components: 97152
  • BCBA interprets results and develops treatment plan: 97151

Authorization limits: Many payers include 97152 within the total assessment authorization (e.g., 8 total units for initial assessment, split between 97151 and 97152)

Supervision requirements: BCBA must be available for consultation during 97152 activities, though not necessarily present in the room

Code 97153: Adaptive Behavior Treatment by Protocol​

Description: Direct implementation of behavior-analytic services following an established treatment protocol. This is the most commonly billed ABA code, representing the direct therapy sessions delivered by RBTs and other qualified personnel.

When to Use 97153​

Bill 97153 when:

  • RBTs deliver direct treatment implementing the established treatment plan
  • BCaBAs provide direct services following the treatment protocol
  • BCBAs provide direct treatment without making protocol modifications during the session

Key requirement: The treatment must follow an established protocol—the treatment plan created by the supervising BCBA. The provider is implementing, not creating or modifying, the intervention.

Who Can Bill 97153​

  • RBTs: Under supervision of BCBA (most common)
  • BCaBAs: Under supervision of BCBA
  • BCBAs: When providing direct service without modification
  • Other qualified personnel: As defined by payer credentialing requirements

Documentation Requirements​

Session notes supporting 97153 must include:

Session logistics:

  • Date, start time, end time, total duration
  • Location/place of service
  • Provider name and credentials
  • Supervising BCBA name

Treatment activities:

  • Specific goals addressed (linked to treatment plan)
  • Interventions implemented
  • Data collected

Performance data:

  • Quantitative measures (percentages, frequencies)
  • Progress toward treatment plan goals

Example compliant note excerpt: "Targeted Treatment Plan Goal 2.1 (manding with 2-word phrases). Implemented DTT with most-to-least prompting hierarchy per treatment protocol. Client demonstrated 18/20 independent mands (90% accuracy). Reinforcement delivered per protocol (high-preference edible after every 3 independent responses)."

Common 97153 Errors​

Error: Billing 97153 when BCBA made significant protocol changes during session Correction: Bill 97155 for BCBA services involving modification

Error: Billing more units than documented time supports Correction: Ensure session start/end times support unit count

Error: Missing treatment plan linkage in documentation Correction: Explicitly reference which treatment plan goals were addressed

Code 97154: Group Adaptive Behavior Treatment by Protocol​

Description: Behavior-analytic treatment provided by a technician (RBT) or assistant behavior analyst (BCaBA) to multiple patients simultaneously, following an established treatment protocol. This is the technician-delivered counterpart to 97157.

When to Use 97154​

Bill 97154 when:

  • RBTs or BCaBAs conduct social skills groups with 2+ clients
  • Technicians deliver group-based instruction following established protocols
  • Multiple clients receive simultaneous treatment in a structured group setting

Key distinctions:

  • 97154 vs. 97153: 97154 is for group settings (2+ clients); 97153 is for individual (1:1) treatment
  • 97154 vs. 97157: 97154 is technician-delivered; 97157 is BCBA-delivered group treatment

Who Can Bill 97154​

  • RBTs: Under supervision of BCBA
  • BCaBAs: Under supervision of BCBA
  • Requires BCBA-developed group treatment protocol

Documentation Requirements​

97154 documentation must include:

Group logistics:

  • Date, start time, end time, total duration
  • Location/place of service
  • Names of all participating clients
  • Provider name, credentials, and supervising BCBA

For each client (individual notes required):

  • Individual treatment goals addressed during group
  • Client-specific performance data
  • Progress toward individual goals
  • Behavioral observations specific to that client

Group rationale:

  • Clinical justification for group format (e.g., social skills development, peer modeling)
  • How group setting supports treatment plan goals

Example compliant note: "Conducted social skills group per established protocol. Group participants: Client A, Client B, Client C. Duration: 60 minutes. Client A targeted Treatment Plan Goal 3.2 (initiating peer interactions). During structured play activity, Client A initiated 4/6 opportunities (67%) with verbal prompt. Client demonstrated appropriate turn-taking in 5/5 trials. Supervising BCBA: John Doe, BCBA."

Billing Rules for 97154​

Per-client billing: Each client in the group is billed separately

Time allocation: Follow payer-specific rules. Common approaches:

  • Full session time billed per client (most common)
  • Divided time (total time ÷ number of clients)

Group size limits: Some payers limit group size (e.g., maximum 8 clients per group)

Ratio requirements: Many payers require specific technician-to-client ratios (e.g., 1:4 or 1:3)

97153 vs. 97154 Decision Guide​

SettingProviderCorrect Code
Individual (1:1)RBT/BCaBA97153
Group (2+ clients)RBT/BCaBA97154
Individual (1:1)BCBA without modification97153
Group (2+ clients)BCBA without modification97157
Group (2+ clients)BCBA with modification97158

Code 97155: Adaptive Behavior Treatment with Protocol Modification​

Description: Services provided by a BCBA that include making modifications to the treatment protocol based on clinical judgment and data analysis during the session.

Understanding "Protocol Modification"​

The key distinction between 97153 and 97155 is modification. 97155 requires the BCBA to actively modify the treatment protocol, not simply observe, supervise, or provide treatment as written.

Activities that support 97155:

  • Adjusting prompting procedures based on real-time client response
  • Modifying reinforcement schedules based on observed motivation changes
  • Changing target criteria based on performance data
  • Updating behavior intervention procedures during session
  • Making treatment plan adjustments based on direct observation

Activities that do NOT support 97155:

  • Simply observing RBT deliver treatment (this is supervision, not billable as direct service)
  • Providing treatment exactly as written in the protocol (bill 97153)
  • Administrative documentation without protocol changes
  • Reviewing data without making modifications

Documentation Requirements​

97155 documentation must clearly demonstrate what modifications were made:

Modification documentation must include:

  • What was changed from the existing protocol
  • Clinical rationale for the modification
  • Data or observation that prompted the change
  • Expected impact of the modification

Example compliant note excerpt: "Observed client during manding program implementation. Performance data showed criterion met for 3 consecutive sessions (90%+ accuracy). Modified protocol: increased target complexity from 2-word to 3-word phrases. Adjusted reinforcement schedule from FR3 to FR5 to promote independence. Updated treatment plan Goal 2.1 accordingly."

Example non-compliant note: "Observed session. Provided feedback to RBT. Reviewed data." (No documented modification = does not support 97155)

97155 Audit Alert

Auditors specifically scrutinize 97155 claims. Your documentation MUST clearly state:

  1. What was changed from the existing protocol
  2. Why it was changed (clinical rationale)
  3. What data or observation prompted the change
  4. Expected outcome of the modification

Simply observing, supervising, or providing treatment as written does NOT support 97155 billing. Many payers cap 97155 at 20% of 97153 units.

97153 vs. 97155: Decision Guide​

ScenarioCorrect Code
RBT implements manding program exactly as written97153 (RBT)
BCBA observes and provides supervision to RBTNot billable as direct service
BCBA provides direct treatment implementing existing protocol97153 (BCBA)
BCBA observes and adjusts prompt fading procedure mid-session97155
BCBA reviews data and updates treatment plan targets97155
BCBA conducts parent training on implementing behavior plan97156

Payer Restrictions on 97155​

Many payers limit 97155 units:

  • Common cap: 97155 limited to 20% of 97153 units
  • Example: If 100 units of 97153 authorized, maximum 20 units of 97155

Document all modifications thoroughly—auditors specifically scrutinize 97155 claims for appropriate use.

Code 97156: Family/Caregiver Training​

Description: Training provided to caregivers (parents, guardians, family members) to enable them to implement behavior-analytic interventions and support treatment generalization.

When to Use 97156​

Bill 97156 when:

  • Teaching parents to implement reinforcement procedures
  • Training caregivers on prompting strategies
  • Demonstrating behavior management techniques
  • Coaching parents through intervention implementation
  • Providing psychoeducation on ABA principles relevant to their child's treatment

Critical distinction: 97156 focuses on training the caregiver, not providing direct treatment to the client. The client may be present, but the service is directed toward building caregiver competence.

Documentation Requirements​

97156 documentation must demonstrate caregiver-focused training:

Required elements:

  • Training topic/objective linked to treatment plan
  • Teaching methods used (instruction, modeling, rehearsal, feedback)
  • Caregiver demonstration/practice
  • Fidelity measurement of caregiver performance
  • Progress toward caregiver training goals

Example compliant note: "Conducted parent training session targeting implementation of DRA procedures for increasing functional communication. Instructed parent on rationale and steps of DRA. Modeled procedure with client across 5 trials. Parent practiced implementation across 10 trials. Fidelity assessment: Parent completed 8/10 steps correctly (80% fidelity). Provided specific feedback on timing of reinforcement delivery. Homework: Practice DRA during mealtimes, record data on provided sheet."

Example non-compliant note: "Met with parent and client. Discussed progress. Worked on communication goals." (Does not document caregiver training or skill building)

Payer Requirements for 97156​

Frequency requirements: Many payers mandate minimum parent training frequency (e.g., 2 sessions/month)

Documentation expectations: Payers expect to see measurable caregiver goals with baseline and progress data

Separate from direct service: Parent training time should be clearly distinguished from direct client treatment time

Code 97157: Group Adaptive Behavior Treatment​

Description: Behavior-analytic treatment provided to multiple patients simultaneously, delivered by protocol. This code is used for group therapy settings such as social skills groups.

When to Use 97157​

Bill 97157 when:

  • Conducting social skills groups with multiple clients
  • Providing group-based instruction following established protocols
  • Delivering simultaneous treatment to 2+ clients

Key considerations:

  • Each client must have individual treatment goals
  • Group must have clinical rationale (not just convenience)
  • Service must follow established protocol (no modification = 97157 vs. with modification = 97158)

Billing Rules for Group Services​

Per-client billing: Each client in the group is billed separately

Time allocation: Total time divided by number of clients, or payer-specific rules

Example: 60-minute group with 4 clients may be billed as 4 units per client (depending on payer guidelines) or split time (15 minutes per client = 1 unit each)

Documentation: Individual progress notes required for each client participating in the group

Code 97158: Group Treatment with Protocol Modification​

Description: Behavior-analytic treatment provided by a BCBA to multiple patients simultaneously, where the BCBA makes modifications to the treatment protocol during the session. This is the group counterpart to 97155.

When to Use 97158​

Bill 97158 when a BCBA:

  • Conducts a group session and modifies treatment protocols based on client responses
  • Adjusts group intervention procedures in real-time
  • Updates treatment parameters for one or more clients during group treatment
  • Makes clinical decisions that change the established group protocol

Key distinction from 97157: The BCBA must actively modify the protocol during the session. Simply delivering group treatment as written is 97157, not 97158.

Documentation Requirements​

97158 documentation must include all 97157 elements PLUS:

Modification documentation:

  • What protocol changes were made during the group session
  • Which client(s) the modifications apply to
  • Clinical rationale for each modification
  • Data or observations that prompted the changes

Example compliant note: "Conducted social skills group with protocol modification. Participants: Client A, Client B, Client C, Client D. Duration: 60 minutes. Observed Client B demonstrating mastery of current conversational turn-taking target (100% across 3 sessions). Modified protocol for Client B: advanced to next objective (initiating topic changes). Adjusted group activity structure to provide more opportunities for Client B's new target while maintaining appropriate complexity for other participants. Updated treatment plan Goal 4.1 for Client B."

Example non-compliant note: "Led group therapy session. All clients participated in activities. Good progress observed." (No documented modification = does not support 97158)

97157 vs. 97158 Decision Guide​

ScenarioCorrect Code
BCBA runs social skills group exactly as planned97157
BCBA runs group and adjusts reinforcement for one client mid-session97158
BCBA runs group and advances one client's target based on mastery97158
BCBA observes technician run group, provides feedback afterNot billable as direct service

Payer Considerations for 97158​

Limited usage: Like 97155, many payers cap 97158 relative to other codes

Documentation scrutiny: Auditors examine 97158 claims carefully; ensure modifications are clearly documented

Authorization: Some payers require specific authorization for group services with modification

Psychological Testing and Evaluation Codes​

While the 97151-97158 codes cover core ABA services, practices conducting autism evaluations or comprehensive psychological assessments may also use testing codes. These codes are typically billed by psychologists or licensed clinicians, though some overlap with BCBA scope depending on state regulations.

96130 and 96131: Psychological Testing Evaluation​

96130 covers the first hour of psychological test evaluation services, including:

  • Interpretation of test results
  • Integration of data from multiple sources
  • Clinical decision-making
  • Report writing

96131 is the add-on code for each additional hour beyond the first. It cannot be billed without 96130.

Billing requirements:

  • Minimum 31 minutes required to bill 96130
  • 96131 billed for each additional 60 minutes of evaluation work
  • These codes cover non-face-to-face professional work

96136 and 96137: Test Administration by Clinician​

96136 covers the first 30 minutes of psychological or neuropsychological test administration and scoring by a physician or qualified healthcare professional.

96137 is the add-on code for each additional 30 minutes.

When these apply:

  • Licensed clinician personally administers standardized tests
  • Commonly used for cognitive assessments, autism diagnostic tools (ADOS-2)
  • Face-to-face time with the patient

96138 and 96139: Test Administration by Technician​

96138 covers the first 30 minutes of test administration by a technician under professional supervision.

96139 is the add-on code for each additional 30 minutes.

Relationship to ABA codes:

  • Similar to 97152 in concept (technician-administered under supervision)
  • Used for psychological testing rather than behavior-analytic assessment
  • May be billed alongside 97151/97152 when comprehensive evaluations include both behavioral and psychological components

When to Use Psychological Testing Codes in ABA Practice​

Appropriate situations:

  • Comprehensive autism diagnostic evaluations
  • Cognitive and adaptive behavior assessments for treatment planning
  • Neuropsychological testing to inform ABA programming

Not appropriate:

  • Routine ABA functional behavior assessments (use 97151/97152)
  • VB-MAPP, ABLLS-R, or similar ABA-specific tools (use 97151/97152)
  • Ongoing skills assessments within treatment (use 97151/97152)

HCPCS Codes for ABA Services​

Healthcare Common Procedure Coding System (HCPCS) codes are used by some payers—particularly Medicaid programs—as alternatives or supplements to CPT codes. State Medicaid programs may require specific HCPCS codes rather than CPT codes for ABA services.

Common HCPCS Codes in ABA Billing​

CodeDescriptionCommon Use
H0031Mental health assessment, by non-physicianInitial behavior assessment (Medicaid)
H0032Mental health service plan developmentTreatment planning (Medicaid)
H2019Therapeutic behavioral services, per 15 minDirect ABA treatment (some states)
S5111Home care training, family, per sessionParent/caregiver training
G2026ABA servicesMedicare RHC/FQHC billing

H0031: Mental Health Assessment​

Description: Mental health assessment by a non-physician provider

ABA application: Used by some Medicaid programs for initial comprehensive behavior assessments. May substitute for or supplement 97151.

Billing considerations:

  • Some states bill per assessment; others use 15-minute increments
  • Often limited to one per recipient per fiscal year
  • May require modifier (e.g., HM for technician-administered portions)

H0032: Service Plan Development​

Description: Mental health service plan development by non-physician

ABA application: Covers treatment plan development activities. Some states use this instead of including planning time in 97151.

Billing considerations:

  • Often reimbursed per event rather than by time
  • May be limited to one per authorization period
  • Documentation must show plan development activities

H2019: Therapeutic Behavioral Services​

Description: Therapeutic behavioral services, per 15 minutes

ABA application: Some state Medicaid programs use H2019 for direct ABA treatment services. Functions similarly to 97153.

Billing considerations:

  • Time-based billing in 15-minute units
  • May require specific modifiers for provider type
  • Check state-specific fee schedules and requirements

S5111: Home Care Training, Family​

Description: Home care training for family members, per session

ABA application: Alternative code for parent/caregiver training. Some payers use this instead of 97156.

Billing considerations:

  • Often billed per session rather than by time
  • May have daily session limits
  • Documentation should demonstrate caregiver skill-building

G2026: ABA Services for RHCs and FQHCs​

Description: Medicare HCPCS code for ABA services in Rural Health Clinics and Federally Qualified Health Centers

When to use: Medicare extended carrier pricing for ABA services through 2026 using this code for RHC/FQHC settings.

State-Specific HCPCS Considerations​

HCPCS code requirements vary significantly by state:

  • Some states transitioned from HCPCS to CPT codes (e.g., Florida in 2022)
  • Others continue using HCPCS exclusively for Medicaid
  • Some use a combination of CPT and HCPCS codes
  • Always verify current state Medicaid requirements
Verify Your State's Requirements

Medicaid billing codes and requirements change frequently. Check your state's current fee schedule and provider manual before billing. Many states have transitioned to CPT codes, but some still require HCPCS codes for specific services.

Category III Codes​

Category III codes are temporary tracking codes used for emerging technologies and services. ABA has two Category III codes for intensive service settings with specific requirements.

0362T: Behavior Identification Supporting Assessment (Intensive)​

Description: Behavior identification supporting assessment, each 15 minutes of technician time face-to-face with patient, requiring specialized equipment and calculation of destructive behavior quotient.

Requirements to bill 0362T:

  • Physician or qualified healthcare provider on-site
  • Two or more technicians present
  • Patient with destructive behavior
  • Customized environment or equipment
  • Destructive behavior quotient calculation

Use case: Intensive assessment settings such as specialized behavioral units or inpatient facilities conducting complex functional analyses of severe problem behavior.

0373T: Adaptive Behavior Treatment with Protocol Modification (Intensive)​

Description: Adaptive behavior treatment with protocol modification, each 15 minutes of technician time face-to-face with patient, requiring specialized equipment.

Requirements to bill 0373T:

  • Same intensive setting requirements as 0362T
  • Physician or qualified healthcare provider on-site
  • Two or more technicians present
  • Customized environment or equipment

Use case: Intensive treatment settings where complex behavioral interventions require multiple staff members and specialized equipment.

Category III Code Limitations​

Limited payer acceptance: Many commercial payers do not reimburse Category III codes. Always verify coverage before billing.

Specific clinical scenarios: These codes apply only to highly specialized intensive settings—not typical outpatient or home-based ABA services.

Conversion to Category I: The AMA periodically reviews Category III codes for potential conversion to permanent (Category I) codes based on usage data.

Category III Codes: Verify Coverage First

Category III codes have limited payer acceptance. Before providing services intended for 0362T or 0373T billing, confirm the payer covers these codes and understand their specific requirements. Most standard ABA services should use the 97151-97158 code family.

Modifier Codes for ABA Billing​

Modifiers provide additional information about the service, typically indicating who provided the service or under what circumstances.

Common ABA Modifiers​

ModifierDescriptionWhen to Use
HOMaster's level providerBCBA services
HNBachelor's level providerBCaBA services
HMLess than bachelor's levelRBT services (some payers)
HPDoctoral level providerBCBA-D or PhD services
95Synchronous telemedicineTelehealth sessions
GTInteractive telecommunicationsTelehealth (alternate)
59Distinct procedural serviceWhen same code billed multiple times same day
XESeparate encounterSeparate session same day
76Repeat procedure by same physicianSame service, same provider, same day
77Repeat procedure by different physicianSame service, different provider, same day

Modifier Selection Guide​

BCBA provides direct treatment: 97153-HO or 97155-HO

RBT provides direct treatment: 97153-HM (payer-dependent)

BCBA conducts telehealth session: 97155-HO-95 or 97155-HO-GT

Two sessions same day, same client, same RBT:

  • First session: 97153
  • Second session: 97153-76 or 97153-XE

Payer-Specific Modifier Requirements​

Modifier requirements vary significantly by payer:

  • Some payers require credential modifiers; others don't
  • Telehealth modifiers differ by payer (95 vs. GT)
  • Some payers use place of service codes instead of modifiers for telehealth
  • Always verify payer-specific modifier requirements

Common Billing Errors and Denials​

Understanding common errors helps you prevent them proactively.

Error 1: Time Documentation Mismatch​

Problem: Billed units don't match documented session time

Example: Session note shows 3:00-3:50 PM (50 minutes) but 4 units (60 minutes) billed

Solution: Always verify documented time supports billed units. Train staff on the 8-minute rule.

Error 2: Incorrect Provider Credentials​

Problem: Service billed under wrong provider type or wrong credential modifier

Example: RBT-delivered service billed with HO (master's level) modifier

Solution: Verify provider credentials match billing submission. Implement billing review processes.

Error 3: Missing Prior Authorization​

Problem: Services provided without valid authorization

Example: Authorization expired, services continued, claims denied

Solution: Track authorization dates, set renewal reminders 6-8 weeks before expiration

Error 4: Insufficient Documentation for 97155​

Problem: 97155 billed but no protocol modification documented

Example: BCBA observed session but note doesn't describe what was changed

Solution: Train BCBAs on documentation requirements; implement note review processes

Error 5: Exceeding Authorization Limits​

Problem: More units billed than authorized

Example: 200 units of 97153 authorized; 250 units billed over authorization period

Solution: Track utilization against authorization; alert when approaching limits

Error 6: Place of Service Errors​

Problem: Incorrect place of service code for where services occurred

Common codes:

  • 12: Home
  • 11: Office/clinic
  • 03: School
  • 02: Telehealth

Solution: Verify place of service matches session location; update when location changes

Error 7: Duplicate Billing​

Problem: Same service billed twice

Example: Session accidentally submitted twice

Solution: Implement claim tracking systems; reconcile submissions regularly

Documentation Requirements by CPT Code​

Each CPT code has specific documentation requirements. Your clinical documentation must support the code billed.

97151 Documentation Checklist​

  • Assessment procedures named and described
  • Assessment tools identified
  • Time spent on each component
  • Interview participants listed
  • Direct observation documented
  • Results/scores reported
  • Function hypotheses stated
  • Treatment recommendations provided
  • BCBA signature with credentials

97153 Documentation Checklist​

  • Date, start time, end time
  • Location/place of service
  • Provider name and credentials
  • Supervising BCBA identified
  • Treatment plan goals referenced
  • Interventions implemented described
  • Performance data recorded
  • Progress toward goals noted
  • Provider signature

97155 Documentation Checklist​

All 97153 elements PLUS:

  • Specific modification made clearly stated
  • Clinical rationale for modification
  • Data/observation prompting modification
  • Treatment plan updated if applicable

97156 Documentation Checklist​

  • Training topic/objective stated
  • Link to treatment plan goals
  • Teaching methods used (BST components)
  • Caregiver demonstration/practice documented
  • Fidelity data on caregiver performance
  • Progress toward caregiver goals
  • Homework/follow-up assigned
  • BCBA signature with credentials

Payer-Specific Billing Considerations​

Different payers have different billing rules, limitations, and documentation requirements.

Commercial Insurance Variations​

Blue Cross Blue Shield (varies by state):

  • May require specific modifiers
  • Different hour caps by plan
  • Some require separate assessment authorization

UnitedHealthcare/Optum:

  • Specific clinical guidelines for service intensity
  • Requires standardized assessments
  • May limit 97155 to percentage of 97153

Aetna:

  • Uses Aetna clinical guidelines for medical necessity
  • Specific documentation format preferences
  • May require peer review for high-hour requests

Cigna:

  • Uses eviCore for behavioral health
  • Specific authorization portal requirements
  • Documentation audits more frequent

Medicaid Billing​

Medicaid billing varies significantly by state:

State-specific considerations:

  • Different authorized provider types
  • Varying hour limits and caps
  • Different modifier requirements
  • Some states use managed care organizations with their own rules

Documentation requirements often stricter than commercial insurance:

  • More detailed session notes required
  • Specific format requirements
  • More frequent progress reporting

Best Practice: Create Payer-Specific Guides​

Document each payer's requirements:

  • Authorized CPT codes
  • Required modifiers
  • Hour limits/caps
  • Documentation requirements
  • Authorization processes
  • Contact information for billing questions

Billing Compliance Best Practices​

Maintaining billing compliance protects your practice from audits, recoupment, and legal issues.

Pre-Billing Review Process​

Implement systematic review before claim submission:

  1. Documentation completeness: Verify all required elements present
  2. Time verification: Confirm documented time supports billed units
  3. Code accuracy: Verify CPT code matches service provided
  4. Modifier check: Confirm appropriate modifiers applied
  5. Authorization verification: Confirm active authorization covers service

Regular Auditing​

Conduct internal audits periodically:

Monthly: Review random sample of claims for accuracy

Quarterly: Compare billed units to documented time across all providers

Annually: Comprehensive billing compliance audit

Staff Training​

Train all staff involved in documentation and billing:

Clinical staff: Documentation requirements by CPT code

Billing staff: Code selection, modifier requirements, payer rules

Supervisors: Oversight responsibilities, audit processes

Record Retention​

Maintain documentation for required periods:

  • HIPAA minimum: 6 years
  • BACB requirement: 7 years
  • Payer-specific: May vary; follow longest applicable period

Billing accuracy in ABA isn't just about revenue—it's about accurately representing the services you provide and maintaining the trust of payers, clients, and the profession. The complexity of ABA CPT codes, modifier requirements, and payer variations can feel overwhelming, but systematic processes and ongoing education make compliance achievable.

The connection between clinical documentation and billing cannot be overstated. When your session notes, treatment plans, and authorization requests consistently support the codes you bill, denials decrease and audits become non-events. Invest in documentation quality, train your team thoroughly, and build review processes that catch errors before claims are submitted.

As ABA practices scale and work with more payers, technology solutions that ensure consistency across documentation and billing become increasingly valuable. Whether through practice management systems, billing software, or AI-powered form automation, the goal remains the same: accurate documentation that supports appropriate billing for the valuable services you provide.