| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Behavioral Treatment Benefit | | 04/23/2024 | Covered and Noncovered Services : CodesTopic #18959 Procedure Codes
Use of CPT procedure codes and applicable modifiers is required on all behavioral treatment claims. Claims or claim adjustments received without an appropriate CPT code and corresponding modifier will be denied. The maximum allowable fee schedule indicates maximum allowable fees and copayment rates.
The following table lists CPT codes and applicable modifiers that providers are required to use when requesting PA and submitting claims for behavioral treatment services. Information on PA coding guidance and procedure codes for claims when commercial health insurance is the primary payer is available. For the full description of current procedure codes and current CPT coding guidance, refer to the current year's CPT code books.
Note: ForwardHealth is required to comply with the CMS NCCI standards. If NCCI standards change, ForwardHealth will comply with the updated standards.
Behavioral Treatment Procedure Codes
| Service Type |
Procedure Code |
Procedure Code Description |
Required Modifier* |
Renderer |
Required Documentation |
ForwardHealth Limits |
| Assessment |
97151 |
Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or other qualified healthcare professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan |
TG or TF |
Licensed supervisor |
- Time in/time out for both face-to-face and non-face-to-face time
- Names of staff and caregiver(s) present
- POS
- Assessment report
- Plan of care
- Renderer's signature
|
PA required for more than 96 units (24 hours) per calendar year; non-face-to-face time should not exceed face-to-face time.** |
| Assessment |
97152 |
Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes |
TG or TF |
Licensed supervisor or treatment therapist |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Assessments completed
- Renderer's signature
|
Service is limited to two hours per DOS. |
| Treatment |
97153 |
Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes |
TG, TF, or TF-52 |
Any level of behavioral treatment provider as indicated by modifier |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Goals addressed and data collected
- Renderer's signature
|
Units per week established via PA. |
| Treatment |
97154 |
Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes |
TG or TF |
Any level of behavioral treatment provider |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Goals addressed and data collected
- Renderer's signature
|
PA required; limited to 8 units (2 hours) per member per DOS. |
| Treatment |
97155 |
Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes |
TG or TF |
Licensed supervisor or treatment therapist |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Goals addressed and data collected
- Renderer's signature
|
PA required; do not bill separately for 97153 during simultaneous direction of technician.*** |
| Treatment |
97156 |
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes (Family Treatment Guidance) |
TG or TF |
Licensed supervisor |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Potential treatment targets identified and/or discussed
- Training, demonstration, observation, and/or feedback provided
- Renderer's signature
|
PA required; limited to 8 units (2 hours) per DOS. |
| Treatment |
97156 |
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes (Team Meeting) |
TG or TF with AM (Physician, team member service) |
Licensed supervisor or treatment therapist |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Potential treatment targets identified and/or discussed
- Renderer's signature
|
PA required; limited to 4 units (1 hour) per week. |
| Treatment |
97158 |
Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes |
TG or TF |
Licensed supervisor or treatment therapist |
- Time in/time out
- Names of staff and caregiver(s) present
- POS
- Goals addressed and data collected
- Renderer's signature
|
PA required; limited to 8 units (2 hours) per member per DOS. |
* TG = Comprehensive treatment, TF = Focused treatment, TF-52 = Focused treatment that can be rendered by technicians
** Providers are required to document exceptional circumstances that require more than 50 percent non-face-to-face hours for behavior identification assessment (procedure code 97151)
*** Providers are required to request all direct treatment units for CPT procedure codes 97153 and 97155 by including the cumulative total of requested treatment units as a single line item using procedure code 97153. Direct treatment units submitted on claims using either of these CPT procedure codes will be deducted from the cumulative total of approved treatment units. |