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
| 299.00 | Autism |
| 299.10 | Childhood Disintegrative
Disorder |
| 299.80 | Asperger's Disorder, PDD NOS, Retts
Disorder |
Procedure Codes
| H0031 | Mental health assessment, by
non-physician
Note: To be used for treatment planning |
| H0032 | Mental 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
