Follow these guidelines when billing ABA services, ASD interventions by multiple providers on the same date of service

Blue Cross Blue Shield of Michigan and Blue Care Network have received claims for autism evaluation and treatment services in which more than one provider is billing for services that occurred at the same time for a single member. 

In general, concurrent billing of services by two or more providers for a member is not eligible for reimbursement. However, this is sometimes appropriate when the member has a diagnosis of autism spectrum disorder, or ASD.

Here are some guidelines for billing for ASD services by multiple providers: 

• Providers can bill concurrently for the following complementary procedure codes, with limitations on duration and frequency:
• *97153 — applied behavior analysis  
• *97155 — protocol modification (supervision)
• Providers cannot bill concurrently for services that occur at the same time but aren’t complementary. For example, don’t bill for applied behavior analysis, or ABA, treatment by a behavior technician and for services by a physical, occupational or speech therapist for the same member between 2 and 3 p.m. on the same date.

Here are some additional guidelines:

• Multiple providers can bill for services for the same member provided on the same date but at different times. For example, billing for these services is acceptable:
• Four units of ABA services provided between 1 and 2 p.m.
• Speech therapy services provided between 2 and 3 p.m.
• Occupational therapy services provided between 3 and 4 p.m.
• The medical necessity of each service must be clearly documented in the member’s medical record. The record must show the interaction among the services and the beneficial effects for the member.

We encourage providers to use their best clinical judgment. Autism-related interventions are difficult and tiring for the member. Take into consideration the fatigue factor, the attention span and the age of the member and the member’s ability to benefit from a specific intervention in light of emotional distress and frustration. For example, it may be hard to justify a speech therapy intervention when the member has already had eight hours of ABA that day. In that situation, the member may not benefit from the speech therapy due to fatigue.

Providers should consider all these factors when determining the medical necessity of the interventions. The medical record must show that the member can benefit from each intervention — rather than simply being present for the session.