When health insurance and government programs first acknowledged Applied Behavior Analysis (ABA) as a medically necessary treatment, there weren’t billing codes specific to ABA. As a result, ABA therapists and billers would have to use generic billing codes to file ABA claims.
This brought confusion and inconsistency to the claims process, sometimes causing denials. The Association for Behavior Analysis International (ABAI) requested the CPT Editorial Panel to amend billing codes to standardize ABA billing in 2012. Consequently, new CPT I and CPT III codes took effect in 2019 to help prove the medical necessity of various ABA treatments and harmonize billing. (Stay tuned, more CPT updates are on the horizon.)
Today, there are 16 CPT codes (0359T-0374T) that guide ABA therapy billing. However, many ABA therapists still face challenges due to code complexity and claims processing issues. Let’s explore how these problems cause hiccups in ABA billing and insurance claims (and what you can do to make your billing workflows easier).
ABA Billing Code Complexity
After completing ABA services, your practice needs to file your claims correctly. This requires accurate coding of each claim with the correct CPT code to ensure approval and payment. Whether your practice bills by hand, Excel, billing software, or utilizes an outside billing team, coding therapy sessions appropriately is essential.
However, ABA billing codes are intricate and specific, so you (or your billing team) must have an in-depth understanding of the system. Here are some reasons that complicate claims processing when dealing with health insurance companies and government programs.
Continuously Changing CPT Codes
One reason why medical professionals like ABA therapists have trouble with billing is the emergence of new codes. Codes change from time to time due to healthcare regulations, among other reasons.
As a result, keeping up with the latest CPT system can be tricky. It’s primarily a problem for newer billing professionals and solo practitioners or small practices where therapists bill for themselves in their downtime.
If your practice has an outdated coding list, you might end up entering the wrong diagnostic codes, treatment codes, or billing codes. Any of these errors can lead to the insurance company denying a client’s claim.
Your practice can overcome this challenge by training your team or billing personnel on the latest billing codes and trends. Staying on top of the current ABA billing codes, guidelines, and procedures will keep your staff ahead of the curve.
Many smaller ABA practices avoid billing headaches by working with an outside managed billing team that provides revenue cycle management services. (WebABA has a dedicated team of ABA billing experts if your practice could benefit from the help.)
CPT Code Categorization
There are two broad categories of ABA billing codes. The first one addresses the client assessment before developing an ABA therapy plan/curriculum.
The initial behavior identification assessment, billed under code 0359T, can have follow-up procedures. These include observational and exposure behavioral assessments. The two steps may each have different billing codes based on the amount of time they take, as below:
- 0360T: Observation assessment sessions below 30 minutes
- 0361T: Observational assessments longer than 30 minutes
- 0362T: Exposure behavioral assessment below 30 minutes
- 0363T: Exposure behavioral assessment longer than 30 minutes
The second category of ABA billing codes, stretching from 0364T to 0374T, covers different ABA treatment services. Just like in the initial assessment, some time-based sessions can have two billing codes.
Codes 0370T to 0373T address therapies that aren’t subject to time, like offering guidance to families in the absence of the patient. Treatments billed differently based on the time spent in each visit go under codes 0373T and 0374T.
This categorization can be confusing when you have other administrative and management roles to keep your practice running. Helpful hint: be sure to monitor your clients’ prior authorizations for sessions and their codes.
Involvement of Multiple Therapists
We’ve seen how complicated billing for a single ABA client for one type of treatment per session can get. What about tracking all the billing details involved when different therapists treat the same client? For example, ABA clients usually work with BCBAs and RBTs (two therapists to bill for). Clients can work with a Speech or Occupational Therapist or multiple RBTs within the same practice, which leads to even more billing complexity.
This can sometimes result in accidental double-billing when rendered sessions, especially when the professionals might not work in the same facility. For example, an in-home RBT visit that a BCBA supervises via a telehealth session could be billed incorrectly.
ABA Billing Procedural Issues
Even with a thorough understanding of ABA billing codes, you can still have trouble with health insurance companies because of in-house billing issues. Below are some mistakes that can increase the risk of claim delays and denials in an ABA practice.
Entering Client Information Incorrectly
Incorrect data entry and typing errors are a reality for many medical offices and ABA therapy practices. For instance, you can misspell a patient’s name or make a typo in the date of birth or policy number.
Insurance companies can deny claims due to even the most superficial errors in client identification information. So, even if you’re in a rush, it’s in your best interest to ensure that all client details are correct. Teach your staff the importance of accuracy and proofreading to reduce errors in claims.
Failure to Confirm Eligibility
ABA therapy coverage can vary with insurance companies. Clients and their families/caregivers might not have all the details about their coverage. They might think that their insurance will cover all aspects of ABA treatment, or they might be unaware of carve-outs.
The health plan can surprise you with rejection if you file claims without verifying a patient’s insurance coverage. This is where eligibility checks and prior authorization management are key to your practice’s financial health and operational workflows.
As a rule of thumb, be sure to confirm your patient’s insurance coverage during the scheduling process. If you don’t have prior authorization management in your practice’s software, be sure to monitor it through other means. (Did we mention WebABA’s practice management system has this feature?) It will save you the trouble of chasing payments or losing revenue.
Not Seeking Referral Authorization
Specialty services providers like ABA therapists get a significant number of clients from referrals. Typically, it happens when a physician or another health care provider feels that therapy is necessary for better patient outcomes.
Most payers expect you to inform them before offering services to a referral under a given plan. The terms may vary with insurance carriers, so it’s best to understand referral policies for various health plans. Before submitting a claim to an insurance company, be sure to include all the relevant referral information.
Sloppy Handwriting and Documentation
Many professionals in the medical field are known for illegible handwriting. A payer can reject a messy claim even if you know your CPT codes and have included all the supporting documentation.
If your data entry personnel cannot read your clinical notes, they might misinterpret the information or even enter the wrong billing codes. Besides denying your claim, a payer can ask for additional details or require you to resend new documentation. It leads to income loss or interruptions in your revenue stream. Of course, this isn’t an issue if you have digital SOAP notes or data collection tools!
Duplicate Record Generation
Another ABA billing mistake emanating from human error is duplicate billing. It usually happens when the billing specialist accidentally submits a claim more than once. It can result in claim denials or delays as you sort the matter out with the patient’s insurance company.
Additionally, filing a claim for a canceled therapy session is a common billing error. You can eliminate it by implementing an ABA practice management system that facilitates proper, accurate services coding. It helps you capture potential duplicates and erroneous entries before submitting claims to insurers.
Missing the Deadline for Claim Submission
Most health insurance companies have strict time frames within which you must submit a claim for services provided. A payer can deny an accurate and properly documented claim if you fail to file it before the deadline.
Medicaid offers a window of up to one calendar year to file claims on your patients’ behalf. On the other hand, most private insurance carriers require you to submit claims within 60 to 90 days from the day of service. Be sure to check the deadline window with the health plans you deal with to avoid surprises.
Tips to Avoid ABA Claim Rejection
Keeping up with ABA billing codes and preparing accurate health insurance billing is no easy feat. Besides CPT codes being hard to master, they keep on changing over the years.
Simple clerical errors like making wrong entries or submitting illegible documentation can lead to a patient’s insurance denying a claim. The result is delayed payment or lost revenue.
If you would like to improve the accuracy and efficiency of your ABA billing system, use the following tips.
Learn How to Submit Claims
Once you’ve prepared a well-documented claim, you need to send it to the payer on paper or electronically. Ensure you have the correct mailing address or submit a soft copy through your electronic health record (EHR) system, clearinghouse, or insurer’s website.
Confirm Your Client’s Demographic Information
Apart from the client’s name, some of their demographic details like age and gender are necessary to complete a claim form. Double-check your client’s data to avoid errors that could lead to a claim denial or delay.
Confirm the Client’s Coverage Eligibility
Before submitting claims, check the client’s insurance policy status to determine their eligibility for coverage. It will save you the disappointment of a claim denial due to a client having exhausted their coverage cap.
Keep a Duplicate of the Client’s Insurance Card
Sometimes you’ll need to verify vital details like a client’s insurance number. Instead of calling them, make a copy of their insurance card for your review when needed. If you have practice management software, their info should be stored in your digital records for easy access.
Watch Out for Claim Submission Deadlines
Most health insurance companies offer a 60 to 90-days allowance for claim submission. Confirm the deadline for various providers and file your claims on time. If a claim is denied and your practice must resubmit, be aware of any deadlines for this process as well.
Key Take Aways
ABA therapy billing and claim submission are challenging processes. Fortunately, you can handle them smoothly and do so much more with WebABA’s Practice Management Software.