The scope of adaptive behavior services is wide and complex, as it includes various types, such as functional behavior assessment and functional analysis. The medical billing process for adaptive behavior assessment (ABA) reflects this complexity.
Dealing with ABA CPT codes and maximizing revenue can be a constant hassle for healthcare providers. Juggling the administrative tasks along with rendering patient care can disrupt the workflow.
That is why healthcare providers and practices need a one-time solution to overcome ABA billing challenges. As we progress in 2025, it’s time to ensure better revenue cycle management with proven solutions and best practices.
This blog is your guide to ABA billing, the common challenges faced by healthcare providers, and solutions to improve the revenue cycle.
The ABA Billing Process: A Comprehensive Guide for Providers
ABA billing involves various steps such as patient registration, insurance eligibility verification, prior authorization, coding, claim filing, and submission. While carrying out these steps, it is crucial for healthcare providers to meet compliance requirements and meet payer guidelines.
What makes ABA therapy intricate is the need to provide long-term and reliable care. This is a full-time job for healthcare providers, leaving limited time for the billing process.
Whether ensuring pre-authorization or streamlining the tracking and management of therapy hours, ABA billing requires proficient handling.
The following are the steps in the ABA billing process:
Insurance Eligibility Verification and Pre-Authorization
The initial step in any medical billing process is checking the insurance eligibility verification and ensuring pre-authorization. Right after a parent makes an appointment for their child or a patient makes an appointment, healthcare providers must carry on with checking the insurance coverage.
Only after this step can healthcare providers move to the next step of offering care to the patient. Once the treatment is done, the process further moves towards documentation and medical coding for claim filing.
Medical Coding and Claim Generation
After completing the verification process and documentation, healthcare providers must translate rendered services into relevant CPT codes and modifiers.
Accurate ABA billing codes and modifiers are a must to ensure proper claim filing. Healthcare providers need to avoid inaccurate codes to uplift the rate of clean claims. Claim filing includes vital information such as authorization units, modifiers, CPT codes, and providers credentials.
Submission of Claims and Claim Processing
After claim filing, it’s time for submission of claims to the insurance provider. The most important part of claim submission is avoiding delays to prevent claim denials.
Claims are first sent to a clearinghouse, where these claims are thoroughly verified to detect errors, if any. When the clearing house approves that there are no errors in the claims, they are sent to the insurance provider.
The task of claim processing is left to the insurance providers, and they take everything into consideration before issuing payment to healthcare providers and practices.
Denial Management to Recover Revenue
If healthcare providers want to enhance ABA billing accuracy and efficiency, they cannot overlook denial management. It plays a crucial role in rectifying errors in denied claims and recovering lost revenue. Not only this, but denial management also identifies the root cause of denials and tries to solve the problem all at once.
So, every healthcare provider must invest their resources in setting up a denial management framework. Denial management improves the ABA billing process and helps healthcare providers attain reimbursement.
Understanding ABA Codes: Key Insights for Accurate Billing
Coding is fundamental to enhancing ABA billing and acquiring desired revenue. Decoding the scope of ABA CPT codes and modifiers is the only way to maximize revenue.
Here’s a list of ABA CPT Codes:
ABA Billing Codes
There are two categories of ABA billing codes, namely Category I Codes and Category III Codes. Category I codes are used for routine services, whereas category III codes focus on new and evolving technologies.
Adaptive Behavior Assessment Codes
These codes are utilized for the assessment of patients, both new and existing.
Category I Codes
- 97151 – Behavior Identification Assessment (Performed by a physician or another certified healthcare provider, calculated on the basis of every 15 minutes)
- 97152 - Behavior Identification Supporting Assessment (Performed by a technician with guidance from a physician or other licensed healthcare provider, calculated on the basis of every 15 minutes)
Category III Codes
- 0362T - Behavior identification as part of the assessment process (calculated every 15 minutes)
Adaptive Behavior Assessment Codes
These codes are utilized for ABA treatment offered according to the ABA assessment.
Category I Codes
- 97153 - Behavior Identification Assessment (Performed by a physician or another certified healthcare provider, calculated on the basis of every 15 minutes)
- 97154 - Group adaptive behavior therapy structured by protocol (Performed by a technician with guidance from a physician or other licensed healthcare provider, calculated on the basis of every 15 minutes)
- 97155 - Protocol-modified adaptive behavior treatment (Performed by a physician or another certified healthcare provider, face-to-face, calculated on the basis of every 15 minutes)
- 97156 - Guidance for family adaptive behavior treatment (Performed by a physician or another certified healthcare provider, face-to-face, calculated on the basis of every 15 minutes)
- 97157 - Guidance for multiple-family group adaptive behavior treatment (Performed by a physician or another certified healthcare provider, face-to-face, calculated on the basis of every 15 minutes)
- 97158 - Modified protocol for group adaptive behavior therapy (performed by a physician or another certified healthcare provider, face-to-face, calculated on the basis of every 15 minutes)
Category III Codes
- 0373T - Behavior treatment with tailored protocol changes (Performed by a technician with guidance from a physician or other licensed healthcare provider, calculated on the basis of every 15 minutes)
Streamlining the ABA Billing Process: Top Tips for Success
Improve Your Initial Workflow
It is vital to establish a strong front-end process and ensure proper insurance eligibility verification. Making things right in the beginning will help you avoid errors in the later stages of ABA billing. Your front-end staff must be proficient at handling the verification process. They must check everything thoroughly and accelerate payment processing.
Outsource Medical Billing Services
Handling ABA billing alone without any expert help is quite a task. Outsourcing your ABA billing process will not only simplify the complex billing task but also help you spend more time improving the quality of patient care.
Moreover, professional medical billers and coders will help you streamline the operations, reduce errors, prevent submission delays, and avoid denials. They work with qualified coders who are well-versed in category I and category III codes capable of optimizing the coding process.
Medical billing services take care of the overall medical billing process, ensuring complete accuracy and efficiency. Partnering with a medical billing company is like shifting your administrative burden and maximizing revenue.
Summary
ABA billing can be challenging for healthcare providers and practices. However, that must not be the reason behind inaccuracies and inefficiencies. If you are looking for ways to improve your ABA billing, then outsourcing medical billing services is an ideal choice for you.
Eminence RCM understands the challenging ABA billing process and offers premium services to handle them. We work with a dedicated team of billers and coders who perform ABA billing proficiently. They take care of all aspects of medical billing, from proper insurance verification to accurate documentation, medical coding, and claim submission.
We also ensure crucial steps like denial management and compliance with HIPAA, so that your patients are never compromised.
Choose Eminence RCM, simplify ABA billing, and maximize reimbursement!
.png)