Coding for Diagnosis and Treatment of Autism Spectrum Disorders Update

As you may be aware, in August of this year, Massachusetts enacted Chapter 207 of the Acts of 2010, which mandates coverage of services related to the diagnosis and treatment of Autism Spectrum Disorders.  Under the law, health insurance carriers are required to cover treatment of Autism Spectrum Disorder, which includes "any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Disorders, including autistic disorder, Asperger's disorder and pervasive developmental disorders not otherwise specified."  Further, the law requires coverage for habilitative or rehabilitative care, including applied behavioral analysis (ABA services).

The law takes effect on January 1, 2011.  Unfortunately, neither the AMA nor CMS have specific codes related to ABA services.  Recently, organizations representing health plans, hospitals and physicians sent letters to these organizations seeking official guidance on the code sets that would accurately reflect the individual components of ABA services.  We recognize that the absence of official guidance may cause some uncertainty over what codes to use and we have been working with a number of provider organizations and other health plans to minimize uncertainty and confusion in this area.  The following HCPCS Level II code sets have been identified that would reflect the component services of ABA and could be used in billing for ABA services:

Diagnosis Codes for Autism

299.00Autism
299.10Childhood Disintegrative Disorder
299.80Asperger's Disorder, PDD NOS, Retts Disorder

Procedure Codes

H0031Mental health assessment, by non-physician
Note: To be used for treatment planning
H0032Mental health service plan development by non-physician
Note: To be used for supervision of services
H2012 Behavioral health day treatment, per hour
Note: To be used for direct services 1, hour increment, BCBA
H2019 Therapeutic behavioral services, per 15 minutes
Note: To be used for direct service, 15 minute increment, paraprofessional

This approach may help to minimize administrative complexity in the billing of these services by utilizing existing codes to recognize these services.  Should you choose not to utilize these codes, you may also follow existing official coding guidelines, which allows for the use of an unlisted code in the absence of a specific code.  However, official coding guidelines require the submission of supporting clinical documentation with the claim and health plans would require submission of this information. 

Additionally, some health plans may have specific requirements concerning the use of modifiers depending on the type of provider that is providing the service.  We would encourage you to contact the health plan directly for any questions you may have about what their requirements are.

Once the appropriate coding entities provide guidance on the code sets that would reflect the component services of ABA or they develop separate codes for ABA services, we will be communicate those changes to reflect the official guidance.

- Provided by the Massachusetts Association of Health Plans

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