CPT Transition Code Information

NC Medicaid has adopted the American Medical Association's new Current Procedural Terminology® (CPT) Category I codes for Research Based Behavioral Health Treatment, effective for dates of service on or after Jan. 1, 2019.

Category III to Category I CPT Code Transition Information

Authorizations
Providers will not need a new authorization from NC Medicaid or their LME/MCO as a result of the transition from Category III CPT codes to Category I codes. Existing (current) authorizations issued by Medicaid or the LME/MCOs remain valid. Please do not submit requests to NC Medicaid or the LME/MCOs asking for existing authorizations to be converted to Category I codes. 

Updates to Existing Authorizations
Effective April 1, 2019, NC Medicaid is converting existing authorizations from Category III to Category I codes. If the care started prior to Jan. 1, 2019, authorized Category III codes will be end dated Dec. 31, 2018. The new Category I codes will start Jan.1, 2019, and remain valid through the current authorization period. 

• NC Medicaid will include the additional 16 units per month of 97155 through the end of the current authorization period on all applicable authorizations. 

All requests for services (initial and ongoing) submitted on or after April 1, 2019 must specify Category I codes/units. NC Medicaid will only authorize to what is documented in the treatment plan. Please update any treatment plan templates to ensure all recommendations are listed in units, not hours. RB-BHT treatment plans submitted after April 1, 2019, without Category I codes/units will not be approved and an updated treatment plan will be requested. 

To convert approved Category III codes/units to Category I codes/units for dates of service on or after Jan. 1, 2019, please use the following conversions. Additional information on descriptions, billing increments, medically unlikely edits (daily limits), restrictions, and exclusions can be found below. 

*RB-BHT providers must complete an individualized clinical evaluation in order to determine the number of units needed for program modification for each beneficiary. For current authorizations issued prior to Jan. 1, 2019, NC Medicaid has determined RB-BHT providers should receive an additional four hours (16 units) per month of 97155 program modification hours in addition to what is currently approved under 0368T/0369T, through the end of the current authorization period.

The additional 16 units per month will allow RB-BHT providers to evaluate the tasks permitted under 97155 and the needs of the beneficiary prior to the next authorization period. At the next authorization period, RB-BHT providers who want to modify their recommended number of units for 97155 should update the treatment plan and include the clinical justification for the modification. The recommended number of units for program modification should be based on an evaluation of a variety of factors including, but not limited to, the intensity of the program, presence of behavior excesses and management of behavior intervention plans, the acquisition rate, frequency and rate of modifications to maintain progress, and the level of modeling to the behavior technician and/or parents. 

**RB-BHT providers who need to adjust the number of units approved for 97156 and 97157 to align with parent training hours can submit a new request for ongoing services. Please include an updated treatment plan with the modified quantities of units for 97156 and 97157along with an explanation of the change with the request.

Claims
All claims for RB-BHT services rendered on or after April 1, 2019, must include Category I CPT codes. Claims will be processed based on the conversion table above.

Continue to bill using Category III codes for ABA services rendered prior to Jan. 1, 2019. 

RB-BHT Billing Codes
Weekly units: The weekly units authorized for 97153 cannot be rolled over to other weeks. The week is defined as Sunday to Saturday. 

Monthly units: The monthly units authorized for 97155 and 97156 cannot be rolled over to other months. The month is from the first day of the approved authorization through the end date of that initial month. Then each month afterward is based on the calendar month. For example, if the authorization starts Feb. 10, 2019, then the first month is Feb. 10–Feb. 28, 2019 and the second month is March 1–March 31, 2019. 

Category I CPT Code Billing Reminders

Concurrent billing: Concurrent billing is excluded for all RB-BHT Category I CPT codes except when the family and the beneficiary are receiving separate services and the beneficiary is not present in the family session. The correct rendering provider must be identified in Box 24J on the claim form. Medical documentation should clearly identify who was present during the session, including all providers, the beneficiary and parents/caregivers, when applicable.

97153 and 97155: Concurrent billing is not permitted. Only one code should be billed when concurrent care services are performed. 

97153 and 97156: Concurrent billing is permitted if the behavior health technician is working with the beneficiary (97153) and the Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP) is conducting parent training (97156) and the beneficiary is not present.

97155 and 97156: Concurrent billing is permitted if the Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP)  is working with the beneficiary (97155) with or without the behavior health technician present and a different Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP) is conducting parent training (97156), and the beneficiary is not present.

97151 and 91753, 97155, 97156: Concurrent billing is permitted if the Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP) is completing an element of the assessment (for example, direct time, report writing) under 97151 and a different Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP) or behavioral health technician is rendering 97153, 97155 or 97156. The beneficiary can only be present for one code. 

Team Meetings: Team meetings are not reimbursable. Please note, that 97155 is not reimbursable for team meetings conducted with school personnel, including attendance at IEPs. This applies to all beneficiaries including those who are approved to receive services in the school setting. 

Program Modification vs. Supervision: 97155 covers adaptive behavior treatment with protocol modification where the Licensed Qualified Autism Professional (LQASP) or Certified Autism Professional (C-QP) resolves one or more problems with the protocol (for example, evaluating progress, progressing programs, modeling modifications, probing skills). As of Jan. 1, 2019, supervision of the assistant behavior analyst and behavior technician, such as treatment fidelity checks and feedback, is not covered. The oversight and supervision of behavior technicians and is required as clinically appropriate and in accordance with the Behavior Analyst Certification Board guidelines and ethics but are not billable.  

Reimbursement Rates