Tiered Payment Rate Modifiers for ABA Effective April 1, 2021

Applied Behavior Analysis (ABA) Therapy is a treatment that is often rendered at a high intensity to individuals from vulnerable populations. The bulk of the therapy hours a member receives is rendered by an unlicensed technician under the supervision of a Qualified Healthcare Professional. To improve the quality of care for our members and be responsive to the needs of our provider network, we will be making some changes to reimbursement rates by allowing the use of modifier codes.

What’s changing?
As part of our initiative to improve health care delivery as well as find solutions to aid in reducing unnecessary health care costs for everyone, we will be implementing a tiered payment rate based on modifiers for CPT® 97153 – ABA Adaptive Behavior Treatment by Protocol. We want our commercial members to receive the best health outcomes for the dollars spent on their care.

Reimbursement Details
Many providers have requested higher reimbursement rates when Licensed Behavior Analysts render this service. Additionally, many providers have inquired if rates were available that 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 our provider network, the reimbursement rate should reflect the education, training and credentials of the clinicians providing care to our commercial members.
Based on the clinician rendering the services, the following modifiers should be used effective April 1, 2021:

  • HN: RBT, Board Certified Assistant Behavior Analyst (BCaBA) or clinician with a bachelor’s degree; rate will remain equivalent to the existing rate.
  • HM: Clinician with less than a bachelor’s degree and no RBT certification; rate will be reduced by 20%.
  • HO: Board Certified Behavior Analyst (BCBA), Board Certified Behavior Analyst – Doctoral (BCBA-D) or clinician with a master’s level or higher education; rate will increase by 20%.

If providers do not include a modifier with code 97153, the reimbursement will default to HM.

Using provider type modifiers to compensate providers of direct services will help to ensure ABA remains a high quality and accessible service for our members.

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