Understanding and Applying CPT Code 97155 for ABA Therapy

CPT code 97155 is a critical billing code in Applied Behavior Analysis (ABA) therapy, covering adaptive behavior treatment with protocol modification administered by a Board Certified Behavior Analyst (BCBA) or other qualified provider. Understanding how to correctly document and apply CPT code 97155 ensures proper reimbursement and compliance with payer requirements.

What Is CPT Code 97155?

CPT code 97155 is used for ABA services that involve individualized treatment and real-time modifications to an existing behavior intervention plan. This service must be provided directly by a BCBA or a qualified health professional working with the client.

Key components of CPT code 97155:

• Direct involvement of the BCBA or a qualified provider
• Modification of treatment protocols in response to client progress
• One-on-one interaction with the patient
• Typically used in conjunction with CPT code 97153 (one-on-one direct therapy provided by a technician under supervision)

When to Use CPT Code 97155

Providers should bill CPT code 97155 when they are actively assessing and modifying a behavior intervention plan during a session with the client. This differs from CPT code 97153, where a technician implements pre-designed interventions without modifications.

Common scenarios for using CPT code 97155 include:

• When a BCBA observes a session and adjusts strategies in real-time
• When immediate modifications are needed based on data collection
• During caregiver training if modifications to the treatment plan are necessary

Documentation Requirements for CPT Code 97155

Proper documentation is essential to support claims for CPT code 97155. Ensure that session notes include:

• The specific goals targeted and progress made
• Modifications to the behavior plan and the rationale behind changes
• The BCBA’s direct interaction with the client
• Data collected before and after intervention adjustments

Failing to document these aspects could result in claim denials or audits from payers.

CPT Code 97155 Reimbursement Considerations

Reimbursement rates for CPT code 97155 vary depending on the payer and state-specific guidelines. Some payers have limits on the number of hours that can be billed per week, and others require pre-authorization for certain ABA services.

Tips to maximize reimbursement:

• Verify prior authorization requirements with insurance providers
• Ensure that documentation aligns with the payer’s medical necessity criteria
• Maintain accurate records of BCBA involvement in treatment modifications

CPT Code 97155 vs. Other ABA CPT Codes

To correctly apply CPT code 97155, it’s crucial to distinguish it from other ABA codes:

• 97153: Direct therapy by a technician (without modification by BCBA)
• 97154: Group adaptive behavior treatment
• 97156: Parent/caregiver training with a BCBA
• 97157: Group caregiver training

By understanding these distinctions, provider groups can ensure accurate billing and compliance with payer guidelines.

Conclusion

CPT code 97155 is an essential component of ABA therapy billing, ensuring that individualized treatment modifications by a BCBA are properly documented and reimbursed. By maintaining thorough session notes, understanding payer requirements, and correctly distinguishing this code from others, ABA provider groups can optimize compliance and revenue cycle management.

For more insights on ABA quality assurance, download our ABA QA Guide.