Inside Behavior Analysis
Volume 2 | 2010 | Number 2
Insurance Billing Code Committee
By Travis Thompson
Currently, nearly 40% of states legislatively mandate reimbursement of applied behavior analysis (ABA) autism early intervention services. As the pace of legislative progress has picked up, more states are likely to join this group supporting ABA autism services over the next few years. In order for ABA providers to be reimbursed by Medicaid or private insurance, such services must be billed using Current Procedure Terminology (CPT) codes. Without appropriate billing codes, there is no way to be paid for performing ABA autism services through medical insurance. CPT codes are owned and regulated by the American Medical Association (AMA) and are the most widely accepted medical nomenclature used to report medical procedures and services. The AMA employs a complex process for evaluating requests for new billing codes.
There are currently no CPT billing codes that accurately match autism ABA early intervention services. Within the existing states mandating reimbursement of such services, a hodge-podge of mental health codes are being used that do not fit our services well and exclude payment for important aspects of our services. Even within a given state, different insurers accept and reimburse services using different CPT billing codes, which creates confusion for families, ABA service providers, and insurers.
About a year ago the ABAI Practice Board consulted with the Executive Council regarding this matter, and the decision was made for ABAI to prepare a Request for New Codes for ABA autism services to be submitted to the AMA New Code reviewing process. A committee was formed and chaired by Travis Thompson and Wayne Fisher, which included representatives from various medical and behavioral subspecialties and disability organizations. Members of the Committee wrote, made suggestions, and edited drafts of the New Code Request:
- American Academy of Child and Adolescent Psychiatry (Bryan King, M.D., and George Realmuto, M.D.)
- Association for Behavior Analysis International (Wayne Fisher, Ph.D.; Louis Hagopian, Ph.D.; Travis Thompson, Ph.D.; and David Wacker, Ph.D.)
- Association for Intellectual and Developmental Disabilities (Mark Yeager, Ph.D.)
- Developmental and Behavioral Pediatrics Section of the Academy of Pediatrics (Michael Reiff, M.D., and Lynn Wegner, M.D.)
- Child Neurology Society (Martha B. Denckla, M.D., and Walter Kauffman, M.D.)
- Pediatric Neurology Foundation (Gary Goldstein, M.D.)
- National Autism Center (Susan M. Wilczynski, Ph.D., Executive Director)
- Private insurance companies (Eric Billington, Ph.D., OptumHealth; William Young, M.B.A., WellSpring Autism Network; and Kristie Thompson, United Behavioral Health)
The final set of proposed codes and the extensive documentation required by the AMA for such requests (approximately 42 pages, mostly single spaced), was submitted in early June for a July 14, 2010 deadline for new proposals. ABAI’s New CPT Code Request will be reviewed at an AMA Committee meeting in mid-October, 2010. If the AMA Committee reviews our request favorably, final action will be made in early February, 2011.
While the availability of new CPT codes does not guarantee a given state’s Medicaid program or insurance company will reimburse using those codes, it greatly increases the likelihood that will happen. The Practice Board has been approached by private insurers that have expressed support for this effort because it will provide them with a consistent, rational means to decide which services to reimburse. According to the Center for Disease Control, there are 730,000 children and youths (individuals ages birth to 21 years) with autism, of which 187,000 are between 2 and 6 years of age, the period when early intensive behavioral intervention is most likely to be implemented. The availability of appropriate CPT codes should make it possible to provide appropriate services to many of these children with autism who could greatly benefit from important early behavioral interventions.