A Bevy of new CPT codes took effect on August 1st of 2021. Many beneficiaries are not eligible for these new codes until their next authorization period after that date. Two of the most common and critical codes affected include the following CPT codes.
- 97157 – multiple family group adaptive behavior treatment guidance
- 97158 – group adaptive behavior treatment with protocol modification
This can include up to 8 families for up to 6 units, which translates into 1.5 hours per day. Though a BCBA or BCaBA might also be allowed to conduct group protocol modification, using CPT code 97158 with up to 8 patients for up to 6 units within a single day.
However, CPT codes 97157 and 97158 need to be requested as part of an authorization process. At the same time, the BCBA must also clearly demonstrate in their treatment plan that the patient has the prerequisite skills to learn or adapt to the treatment strategy’s goals in a formal group format.
What this means in a real-world context is that a lot of families can actively participate in group therapy as well as things like parent training. This is a real benefit to some families.
However, all providers still need to bear in mind that group therapy that uses a BT 97154 code is still not covered under the new changes enacted on August 1st of 2021. Using the wrong code in these instances can directly lead to a claim denial or an initial claim rejection.
Considering the impact that a claim denial of delay can have on the family, the patient, and your practice’s revenue stream, we decided it was a good idea to take a closer look at some potential real-world examples of when CPT Code 97157 and CPT code 97158 might be used.
When To Use CTP Code 97157
CPT Code 97157 is recognized by American Medical Association, as a medical procedural code under the range of Adaptive Behavior Treatment Procedures. It involves the provider discussing with multiple patients in a face–to–face setting with a group of guardians, parents, or direct caregivers, without the respective patients being physically present. This code needs to be reported for every 15 minutes that the provider spends engaged in the face–to–face interactions with multiple sets of caregivers, parents, or guardians.
In an ABA setting, this might be a provider consulting with caregivers and family members of a child with autism spectrum disorder. It provides an opportunity for everyone to compare their experiences with the child, which can help identify specific triggers and triggering emotions, as well as gauge the patient’s response.
This can help the ABA provider, who is overseeing the child’s therapy to develop an effective treatment plan or modify an existing treatment plan. The child not being present for this group session can help all family members to be more candid, and might play a role in the modified treatment plan the ABA provider develops.
Under the new guidelines enacted on August 1st, 2021 the maximum number of units that CPT code 97157 can be billed under is 6, units, with one unit being equal to 15-minutes or 1.5 total hours. Anything beyond 6 units will likely not be reimbursed by the payer or public health institution. This makes planning and maintaining the flow of the conversation important in more intensive cases.
When To Use CTP Code 97158
CPT code 97158 maintained by American Medical Association, is a medical procedural code under the range for Adaptive Behavior Treatment Procedures. It is intended to be used any time a provider administers adaptive behavior treatment to multiple patients in a social skills group. This code should be reported for each 15-minute unit that the provider spends face–to–face with multiple patients in a group setting.
A real-world example of when to use CPT Code 97158 would be a patient or group of patients with autism spectrum disorder who have been struggling to develop healthy social skills. Meeting in a group that is coordinated and facilitated by the provider can help guide these patients to interact with each other in a more socially acceptable and positive way.
This might be daily “Group” meetings bi-weekly or even weekly meetings with patients who are at the same relative social and communication skill level.
Under the new guidelines enacted on August 1st of 2021 the maximum number of units that CPT code 97158 can be billed for up to 6, 15-minute units for a total of 1.5 hours in a day. Beyond 6 units will likely not be reimbursed by the payer or public health institution.
Also note that the group size allowed under CPT Code 97158 must be 8 or fewer patients, which also needs to be taken into account when planning and scheduling group sessions.
Knowing When To Use CPT Codes 97157 & 97158 In Medical Billing
If you are a small practice or solo practitioner, your focus needs to be on providing your patients with the highest level of care. This can be especially challenging in group dynamics, where CPT codes 97157 and 97158 can be applied. Staying on the same page with parents, guardians, and caregivers, or a diverse group of patients requires tight focus and versatility.
In times like this, a lot of practitioners and ABA therapists who specialize in group-setting therapy plans will turn to an outside medical billing agency like Operant Billing Solutions to handle their coding and medical billing needs.
Our highly trained and experienced professional coders know precisely when and how to apply critical group therapy codes like CPT codes 97157 and 97158. This includes making sure that all the necessary information and documentation for each member of the group is included, as well as combing through every claim for even the smallest of potential errors of empty fields.
This level of intense, professional scrutiny will go a long way toward preventing claim denials and claim delays from insurance payers and public health institutions. All while letting you stay focused on the fluidity of the group therapy dynamic.