TRICARE is announcing an exception to policy regarding the use of Telehealth (TH) capabilities for Applied Behavior Analysis (ABA)

March 31, 2020

Attention ABA providers:

TRICARE is announcing an exception to policy regarding the use of Telehealth (TH) capabilities for Applied Behavior Analysis (ABA) services specifically during this COVID-19 pandemic.

During effective dates of March 31, 2020 through May 31, 2020, (“emergency period”), TRICARE is permitting the unlimited use of only CPT code 97156 Parent/ Caregiver Guidance when synchronous telehealth services are used for beneficiaries with a current active authorization. DHA will provide additional guidance should the emergency period extend past May 31, 2020.

  • CPT code 97156, in person or via TH, may be rendered by only Board Certified Behavior Analysts and assistant behavior analysts.
  • CPT Codes 97151, 97153, and 97155 continue to be prohibited for delivery via TH.
  • The contractor shall remove the Medically Unlikely Edit (MUE) only for CPT code 97156 when it is done via TH to allow for the temporary provision of rendering unlimited CPT code 97156 via TH.
  • On any date of service, if the GT modifier is used for CPT code 97156, only 97151 and T1023 shall be payable in addition to 97156/GT. All other CPT codes filed on the same date of services as CPT code 97156/GT shall be denied reimbursement.
  • On any date of services where CPT code 97156 is filed without the GT modifier, all CPT codes in the existing ABA authorization for that beneficiary shall be payable.
  • No additional authorization is required, and no changes to the existing authorization, including expiration dates, will be required of the contractors. Maintaining the current authorization ensures that all submitted claims are tied to an existing authorization, therefore preventing any non-authorized Autism Care Demonstration (ACD) claims from being paid.
  • For new authorizations resulting from new referrals during this unique period, CPT code 97151 will be issued to complete an indirect assessment, review of records and development of a treatment. The treatment plan should be developed with the full recommendation of all CPT codes for the six-month authorization period. Any program modifications may be completed under in-person CPT code 97155 once the social distancing provision is lifted.
  • Should the ABA provider render CPT code 97156 via TH, the claims filed must include the GT modifier and Place of Service code 02 or the claim shall be denied.
  • Every session rendered via 97156 TH shall adhere to the same documentation standards set forth in TOM Chapter 18, Section 4, Paragraph 17.2. to include documenting Place of Services 02.
  • All other criteria defined in TPM Chapter 7, Section 22.1 “Telemedicine” apply including the use of a HIPAA compliant platform, and compliance with all state/country licensing and privileging practice laws.
  • For authorizations that expire during this specified window, the ABA provider may submit CPT code 97151 since much of that time is used for completing the treatment plan update via indirect services. All requirements of CPT code 97151 still apply.
  • No extensions to the authorization timeline will be granted. For authorizations expiring during this period, and subsequent authorization requests, all relevant requirements (i.e., the PDDBI) are expected to be completed on time.
  • No retro-authorizations or extensions to the timeline will be authorized.
  • No other ACD program requirements will be exempt.

Additionally, providers should anticipate longer processing and payment times for claims as this policy exception is being implemented.

The implementation date for this change is March 31, 2020 and the effective date is March 31, 2020.

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