September 29, 2023
Applied Behavior Analysis (ABA) Therapy is a treatment that is often rendered as a high intensity treatment to members in vulnerable populations. Most of the ABA therapy hours a member receives are rendered by an unlicensed technician under the supervision of a qualified health care professional. To support quality care for our members and remain responsive to the needs of participating providers, Blue Cross and Blue Shield of Illinois (BCBSIL) will be making some changes to reimbursement rates by allowing the use of modifier codes on some commercial claims.
What’s changing?
As part of our initiative to improve health care delivery as well as to find solutions to aid in reducing unnecessary health care costs, BCBSIL will be implementing a tiered payment rate based on modifiers for Current Procedural Terminology (CPT®) code 97153 (ABA adaptive behavior treatment by protocol). This change applies to applicable services rendered to eligible commercial, non-HMO members. This information doesn’t apply to government programs (Medicare Advantage and Illinois Medicaid) or any of our delegated HMO members.
Reimbursement Details
Many providers have requested higher reimbursement rates when Licensed Behavior Analysts render ABA therapy services. Additionally, many providers have inquired about availability of rates to reflect their commitment to best practices by ensuring all their Registered Behavior Technician (RBT) staff obtain and maintain certification. Based on similar changes across the industry and feedback from participating providers, the reimbursement rate should reflect the education, training and credentials of the clinicians providing care to our commercial members.
The following reimbursement methodology for CPT code 97153, based on the provider type (clinician rendering the services), will be effective Jan. 1, 2024:
- Modifier HN – For RBT, Board Certified Assistant Behavior Analyst (BCABA) or clinician with a bachelor’s degree, the rate will remain equivalent to the rate on CPT code 97153 in effect as of June 1, 2023.
- Modifier HM – For a clinician with less than a bachelor’s degree and no RBT certification, the rate in effect for CPT code 97153 as of June 1, 2023, will be reduced by 20%.
- Modifier HO – For a Board Certified Behavior Analyst (BCBA), Board Certified Behavior Analyst - Doctoral (BCBA-D) or clinician with a master’s level or higher education, the rate in effect for code 97153 as of June 1, 2023, will be increased by 20%.
Note: If providers don’t include a modifier with code 97153, the reimbursement will default to the equivalent of Modifier HM. All rates are subject to change at any time at the discretion of BCBSIL.
Thank you for helping us ensure that high quality ABA services remain accessible and affordable for our members.
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