When health insurance first acknowledged applied behavior analysis (ABA) as a medically necessary treatment, there weren’t billing codes specific to ABA. As a result, therapists would use different billing codes to make similar ABA claims. This brought confusion and inconsistency in claims data, sometimes causing claim 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.

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 procedural issues. Let’s see how these problems cause hiccups in ABA billing and insurance claims.

ABA Billing Code Complexity

After offering ABA services, you need to file your claims correctly. It requires accurate coding of each claim with the correct CPT code. By so doing, you increase the chance of the payer approving your claim.
However, ABA billing codes are intricate and specific, so you must understand them in depth. Here are some reasons that complicate claims processing when dealing with health insurance companies.

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 is somewhat tricky. It’s primarily a problem for inexperienced billing professionals and solo therapists who haven’t specialized in CPT codes.

If you have an outdated codebook, you might end up entering the wrong diagnostic codes, treatment codes, or billing codes.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 patient’s claim.

You 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 and procedures will keep your staff ahead of the curve.

CPT Code Categorization

There are two broad categories of ABA billing codes. The first one addresses the patient assessment before developing an ABA therapy plan.

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.

Involvement of Multiple Therapists

We’ve seen how complicated billing a single patient for one type of treatment per session can get. What about tracking all the billing details involved when different therapists treat the same patient? 

It sometimes results in double billing, especially when the professionals don’t work in the same facility. Essentially, double billing refers to when different providers serving a patient within the same period bill the payer for all the hours.

If you worked as a team, the leader could bill the total amount of time if the other therapists took subordinate roles. Otherwise, you can split the time depending on hours worked and apply different CPT codes.

Procedural Issues in ABA Billing 

Even with an 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 Patient Information

Incorrect data entry and typing errors are a sad 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 patient identification information. So, even if you’re in a rush, it’s in your best interest to ensure that all patient details are correct. Teach your staff the importance of accuracy and proofreading to reduce errors in claims.

Failure to Confirm a Patient’s Policy

ABA therapy coverage can vary with insurance companies, and patients aren’t wholly conversant with their policies. They think that their insurance will cover all aspects of their ABA treatment.

If you file claims without verifying a patient’s insurance coverage, the health plan can surprise you with rejection. It can occur when dealing with someone who recently changed their policy or a patient who doesn’t understand their insurance coverage.

As a rule of thumb, be sure to confirm your patient’s insurance coverage during the scheduling process. It will save you the trouble of chasing payments or losing revenue.

 Authorization Management

Specialty services providers like ABA therapists get a significant number of patients from referrals. Typically, it happens when a physician or another health care provider feels that therapy is necessary for better patient outcomes. Prior authorization management is essential to ABA therapy practices.

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 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. 

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.

Submit Claims Correctly

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 patient’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 Patient’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 patient having exhausted their coverage cap or units on an authorization.

Keep a Duplicate of the Patient’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.

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.

The Key Takeaway

ABA therapy billing and claim submission are challenging processes. Fortunately, you can handle them smoothly and do so much more with WebABA Profession’s Practice Management Software.

Download our claim submission cheat sheet below for an easy ABA billing checklist.