Make Your Voice Heard -- Preserve & Expand Access to Autism Treatment
NCAAS is the voice of autism service providers who, in turn, represent thousands of families affected by autism. NCAAS works to secure and expand access to services and supports for individuals affected by autism spectrum disorder and their families. NCAAS efforts benefit enormously from simultaneous grassroots advocacy. Check back often to learn about ongoing grassroots efforts
Updated January 1, 2019
New 2019 cpt i billing codes take effect
Most billing codes for adaptive behavior services transitioned from CPT III (temporary) status to CPT I (permanent) status, effective January 1, 2019. Providers should be aware of potential changes in billable activities. For example, behavior analysts have historically characterized their oversight of the treatment plan and the behavior technicians as “supervision.” Going forward, it may be helpful to integrate the terminology in the billing codes, such as direction of the technician and protocol modification. If a funding source interprets the CPT I codes to exclude activities that were previously billable, the cost of those activities should be contemplated when identifying and negotiating sustainable rates.
Although funding sources have the latitude to interpret the billing codes differently, a lack of standardization may be indicative of a need for clarification in the code descriptors or even the need for the development of a new code. As the funding sources make their definitions of the codes available, NCAAS will analyze the inconsistencies to identify whether formal action should be considered.
To learn more about the CPT 1 codes, consider purchasing the CPT Changes and CPT Assistant documents published by the American Medical Association.
what are Medically Unlikely Edits?
Many of you have noticed that the CPT I codes have been assigned Medically Unlikely Edits (MUEs). MUEs are assigned by the Centers for Medicaid and Medicare Services (CMS). An MUE is the maximum number of units that a provider would typically report for a single patient in one day. When your billable services exceed the MUEs, the claim for those services is likely to be denied automatically by the funding source’s claims system. Some of the MUEs assigned to the adaptive behavior codes are too low, and NCAAS is reaching out to CMS to increase the MUEs to facilitate ABA that reflects best practices.
MUEs should never be a basis for the denial of medically necessary treatment. Encourage funding sources to individualize treatment decisions, and be prepared with a clinical rationale if your patient requires services that exceed the MUEs. Funding sources should offer modifiers to ensure your claims are paid when the MUEs are exceeded but authorized by the funding source.
Current MUEs for the adaptive behavior codes are:
97151 - Behavior Identification Assessment — 32 units per day
97152 - Behavior Identification Supporting Assessment — 8 units per day
97153 - Adaptive Behavior Treatment by Protocol — 32 units per day
97154 - Group Adaptive Behavior Treatment by Protocol — 12 units per day
97155 - Adaptive Behavior Treatment with Protocol Modification — 24 units per day
97156 - Family Adaptive Behavior Treatment Guidance — 16 units per day
97157 - Multiple-Family Group Adaptive Behavior Treatment Guidance — 16 units per day
97158 - Group Adaptive Behavior Treatment with Protocol Modification — 16 units per day
0362T - Behavior Identification Supporting Assessment w/4 Required Components — 8 units per day
0373T - Adaptive Behavior Treatment with 4 Required Components (for patients exhibiting destructive behaviors) - 32 units per day
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National health care action - May 4, 2017
The House passed the American Health Care Act (AHCA) today without ensuring affordable access to meaningful insurance for people with pre-existing conditions, including people with autism. As the bill moves to the Senate, we expect to see many changes. We know that Senator McConnell is actively meeting with Republican senators to craft a bill that can garner 51 votes in the Senate. Please contact your senator and urge him/her to ensure coverage of pre-existing conditions at affordable rates; minimum benefits requirements, including mental health coverage; and Medicaid funding that does not cap enrollment.
As we turn our attention to the Senate, remember that the bill will eventually go back to the House for a vote on the Senate version. Please take a moment to thank those representatives who opposed the bill, especially the Republicans:
Andy Biggs (Ariz.) 202-225-2635
Mike Coffman (Colo.) 202-225-7882
Barbara Comstock (Va.) 202-225-5136
Ryan Costello (Pa.) 202-225-4315
Charlie Dent (Pa.) 202-225-6411
Dan Donovan (N.Y.) 202-225-3371
Brian Fitzpatrick (Pa.) 202-225-4276
Jaime Herrera Beutler (Wash.) 202-225-3536
Will Hurd (Texas) 202-225-4511
Walter Jones (N.C.) 202-225-3415
David Joyce (Ohio) 202-225-5731
John Katko (N.Y.) 202-225-3701
Leonard Lance (N.J.) 202-225-5361
Frank LoBiondo (N.J.) 202-225-6572
Thomas Massie (Ky.) 202-225-3465
Pat Meehan (Pa.) 202-225-2011
Dave Reichert (Wash.) 202-225-7761
Ileana Ros-Lehtinen (Fla.) 202-225-3931
Chris Smith (N.J.) 202-225-3765
Mike Turner (Ohio) 202-225-6465
Summary of AHCA
The latest amendment to the American Health Care Act (AHCA) does nothing to address the numerous problems that would arise for Americans with pre-existing conditions if AHCA were to pass. AHCA would have a devastating impact on people with pre-existing conditions, including people with autism. It would allow states to shift people with pre-existing conditions into high-risk pools where they could wait more than a year for limited insurance coverage. The budget for these high-risk pools is badly underfunded, which would force states to ration medically necessary care. AHCA would allow states to eliminate the minimum coverage created by Essential Health Benefits (EHBs) and remove the federal match for Medicaid dollars. People who are insured through their employers could lose meaningful health insurance coverage because large employers could base coverage on the state plan in any state in which that employer is located. That means, you could live in California or Massachusetts and get insurance from a state with much more limited coverage. This bill still shifts nearly a trillion dollars from Medicaid over the next 10 years. People who rely on Medicaid would find limited services that are constantly being scaled back by states that can't afford to prop them up without federal dollars.
People who are healthy now would think they had meaningful health insurance until they tried to use it; without Essential Health Benefits, insurers could sell policies without meaningful coverage. Remember, we will all eventually have pre-existing conditions! We need health care that doesn't discriminate against people with autism.
Call Your Elected Representatives! (866) 426-2631
Take action today by contacting your senators and representatives! If your elected representatives didn't support the last version of the ACHA, be sure to thank them for their thoughtful decision. Then, urge them not to support this latest version of the AHCA. Tell them how it would affect you personally if health insurance doesn't have to offer real coverage with Essential Health Benefits and if insurers can charge more to people with pre-existing conditions or shift them into underfunded high-risk pools. If Medicaid helps you today, share your story about why Medicaid federal dollars must stay in place. Find your elected representatives here.
Attend a Town Hall
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Find your elected official here.