Understanding and Applying the 97155 CPT Code

CPT Code 97155: Adaptive Behavior Treatment with Protocol Modification

In Applied Behavior Analysis (ABA), accurate billing and compliance are essential for ensuring high-quality care and appropriate reimbursement. One of the most frequently used codes for ABA therapy is CPT code 97155, which covers adaptive behavior treatment with protocol modification.

This guide provides a comprehensive overview of 97155, including:

• Its correct definition and clinical application
• When to use 97155 versus other ABA CPT codes
• Documentation and billing requirements
• Common errors to avoid

By understanding the specific requirements for this code, ABA professionals can improve compliance, reduce claim denials, and enhance the integrity of treatment delivery.

What Is CPT Code 97155?

97155 – Adaptive Behavior Treatment with Protocol Modification

CPT 97155 is a direct service code used when a BCBA or licensed behavior analyst actively modifies an individualized treatment plan based on real-time client performance. This modification must occur during the session and must be clinically necessary for improving treatment outcomes.

Key Criteria for 97155:

• Provided by a BCBA, licensed behavior analyst, or other qualified professional
• Requires direct interaction with the client (not just supervision)
• Involves real-time protocol modifications based on client response
• Billed in 15-minute increments
• Used for one-on-one treatment only (not group or caregiver training)

When to Use CPT Code 97155

This code should be used when:

1. Modifying an Active Treatment Plan:

The client is not responding as expected, and the BCBA adjusts reinforcement schedules, prompting strategies, or task difficulty during the session.

The client displays challenging behavior, requiring immediate modification to the behavior intervention plan (BIP).

2. Adjusting Treatment Based on Real-Time Data:

The BCBA collects session data and identifies the need to change instructional strategies for improved progress.

Treatment intensity is increased or decreased based on the client’s learning rate.

3. Ensuring Treatment Fidelity and Effectiveness:

The BCBA modifies task presentations in discrete trial training (DTT) or natural environment teaching (NET) based on real-time assessment.

When NOT to Use CPT Code 97155

For Initial Assessments: Use 97151 (Behavior Identification Assessment) instead.

• For Following an Unchanged Treatment Plan: Use 97153 (Adaptive Behavior Treatment by Protocol) instead.
• For Parent Training: Use 97156 (Family Adaptive Behavior Treatment Guidance) instead.
• For Group Sessions: Use 97154 (Group Adaptive Behavior Treatment) instead.

Proper documentation is essential for insurance compliance, reimbursement approval, and clinical integrity.

Required Documentation for 97155:

• Session Date & Time (Start and end time; must support 15-minute increments)
• Treatment Modifications (Specific changes made and the rationale)
• Client Response to Modification (How the client’s behavior or skill acquisition was affected)
• Data Collection and Analysis (Objective data supporting the modification)
• Future Treatment Plan Adjustments (How this session informs upcoming treatment)

Example of a Correct 97155 Session Note:

“During today’s session, the BCBA observed that the client was not engaging with the current prompting strategy. The BCBA modified the intervention by introducing errorless learning instead of least-to-most prompting. Following this change, the client completed 4 out of 5 trials successfully. Data was recorded on response latency, and further modification will be assessed in the next session.”

Common Documentation Mistakes to Avoid

• Failing to Document Protocol Modifications: If no change was made, 97155 should not be billed.
• Not Specifying BCBA’s Direct Involvement: 97155 requires active BCBA participation, not just passive supervision.
• Overusing 97155 When 97153 is More Appropriate: If the session follows an existing protocol without adjustments, 97153 should be used instead.
• Billing 97155 for Indirect Work: Reviewing data outside of session time does not qualify for 97155.

ABA provider groups must ensure that the use of 97155 aligns with insurance policies and compliance requirements. Failure to adhere to these standards can result in denied claims, audits, and financial penalties.

Key Compliance Considerations:

• Preauthorization Requirements: Some payers require prior approval for 97155. Always verify before billing.
• Session Length Compliance: Ensure that the billed time matches the documented session duration.
• Adherence to Scope of Practice: Only BCBAs or licensed behavior analysts can provide services under 97155.
• Ethical Use of 97155: Avoid upcoding or unnecessary billing when treatment modifications are minimal or not clinically necessary.

Regulatory Changes & Policy Updates

CPT coding guidelines are periodically updated. It is critical for ABA compliance teams to:

• Monitor payer-specific policy changes regarding 97155 coverage and documentation standards.
• Stay updated on CPT code revisions from the American Medical Association (AMA) and insurance payers.
• Conduct internal audits to ensure 97155 is used correctly and documentation supports medical necessity.

Key Takeaways for Quality Assurance Teams

• 97155 is for protocol modifications made in real-time during direct client interaction.
• Billing must be supported by documentation that includes the modification rationale and client response.
• 97155 cannot be used for passive supervision, data review, or initial assessments.
• Incorrect use of 97155 can lead to claim denials, audits, and compliance risks.

By implementing rigorous quality assurance protocols, ABA provider groups can maintain ethical billing practices, improve claim approval rates, and ensure that clients receive the highest quality care.