Have more questions? Email admin@virginiaaba.org
Here is some billing guidance directly from DMAS (11/18/21). The manual was updated on 11/30 and can be found here. (Appendix D is specifically regarding ABA – the third service of three – but pay special attention to chapters IV and VI as well; there is also a Telehealth appendix). The rates can be found here. New Q&As were posted by DMAS on 1/18/22 and can be found here.
Background:
- Before DHP (Department of Health Professions) licensure (through the Board of Medicine), there was an Outpatient ABA license through DBHDS (Department of Behavioral Health and Developmental Services).
- This service was difficult for in-home providers since it was geared toward a clinic (asking for temperature of water, number of fire extinguishers, etc.)
- It became unnecessary in 2012 when DHP began licensing behavior analysts through the Board of Medicine
- In 2014, a couple of years after our license was affirmed, DMAS (Department of Medicaid Assistance Services) created a service called Behavioral Therapy that would allow LBAs and other LMHPs to practice under their state issued licenses rather than a separate license from DBHDS. This service was not specifically ABA and encompassed other professions in addition to behavior analysis.
- In January 2019, Category 1 codes went into effect for behavior analysts. This was a behavior analyst-led initiative, and the codes are approved by the American Medical Association but put forth by a Coding Coalition made of behavior analysts. For more information, see www.abacodes.org.
- The Center for Medicare & Medicaid Services (CMS) has issued a statement on correct coding and the necessity of using codes that correspond with the service one is providing. For more information, see https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html.
- Project BRAVO (Behavioral Health Enhancement) was launched by the Virginia Legislature which directed DMAS to improve Behavioral Health Services in 2018. For more information on that initiative, see https://www.dmas.virginia.gov/for-providers/behavioral-health/enhancements/ or this VABA post: https://virginiaaba.org/behavioral-health-redesign/. One of the service enhancements is Multisystemic Therapy (MST) and the correct code for that service is H2033, the same code that is being used by Behavioral Therapy.
- In 2021, VABA submitted a budget amendment in partnership with DMAS to do a rate study to move ABA to its correct codes thus freeing up the H2033 code for MST. The legislation indicated that the code changes should take place on 12/01/2021, which brings us to the situation where we are today.
- Note that DMAS held two trainings: one with Mercer on how the rates were established (held 10/21) and the other with Dr. Ward on the new ABA Manual (held 10/26). Follow Virginia Medicaid on YouTube for these and other trainings. The manual should be posted around the second week of November 2021, and the Q&A from the trainings should be posted close to 12/1/21 on https://dmas.virginia.gov/for-providers/behavioral-health/.
See our Q&As below. These answers are accurate to the best of our knowledge and not officially approved by DMAS. If you receive conflicting information, please email admin@virginiaaba.org to let us know so that we can research and correct if necessary. Updated 10/29/21 to include questions from the DMAS trainings.
Q. I understand that I cannot bill for indirect work, like supervision without the client present, data analysis, and materials creation. How am I supposed to keep behavior technicians if they do not get paid for that anymore?
A. First, you should absolutely pay your behavior technicians for every hour they work, be it through an hourly wage or
salary. Behavior technicians MUST NOT be contractors. They have to be paid as employees for all work they perform. See
the BACB November 2018 newsletter (https://www.bacb.com/newsletters/) and also guidance from the IRS on this (https://www.irs.gov/businesses/small-businesses-self-employed/independent-contractor-self-employed-or-employee). Also make sure that you are paying at least minimum wage (see https://virginiaaba.org/aba-businesses-and-minimum-wage/).
Indirect services such as supervision without the client present and data analysis are “in kind” services and thus included in the rate
you are contracted to bill. It is incumbent upon business owners to determine how to run their businesses in order to pay their employees an adequate wage, and billing and salaries do not correspond one-to-one.
Update: It seems the Medicaid will allow LBAs to bill for “ongoing assessment, data analysis
and time spent adjusting the treatment plan” without the child present despite the fact that the 97155 code is not meant for those services. DMAS used to limit that billing to the same day as when the youth was seen face-to-face, but that restriction is now gone.
Q. Why has the BT rate been lowered?
A. There was not an actual behavior therapist rate for behavioral therapy. The rate was a blended rate of $60/hour or $15/unit that encompassed both behavior techs and licensed persons. It was assumed that the rate was low for licensed professionals and high for unlicensed professionals and that the blending would meet somewhere in the middle. As was the case before, companies should look at the LBA and BT rates together when setting salaries for staff and covering overhead and operating expenses, not as one-to-one correspondence.
Here are two articles that may be useful for you:
Understanding the difference between operating expenses and overhead
Q. In the manual for public comment, LABAs were equated to Behavioral Technicians (technically unlicensed persons) and not able to supervise. Will this be the case when the manual is approved?
A. No. DMAS has made changes and there will be modifiers for LABAs in all codes where LBAs can provide services. LABAs must follow the law and their supervision agreements, and cannot bill independently.
Q. Is supervision required weekly as it said in the draft manual?
A. No. This has been changed to “Supervision of unlicensed staff shall occur at least twice a month by the licensed supervisor. As documented in the youth’s medical record, supervision shall include a review of progress notes and data and dialogue with supervised staff about the youth’s progress and effectiveness of the ISP. Supervision shall be documented by, at a minimum, the contemporaneously dated signature of the licensed supervisor.”
Q. Will pre-existing authorizations for H2033 be honored until their expiration date? Or do they need to be resubmitted?
They will be honored. Some payors, such as Anthem, are going to have everything switch over to the 97155 code and rate (for LBAs) in the interim. Any future service authorizations will be aligned with the correct CPT codes.
Q. Can LMHPs other than LBAs deliver this service?
A. This does not have simple answer and is still being explored by VABA with the help of APBA who provided the following information.
There is an exception to our licensure law that says: “The provisions of § 54.1-2957.16 shall not be construed as prohibiting any professional licensed, certified, or registered by a health regulatory board from acting within the scope of his practice.”
“Scope of practice” in this context refers to the definition of the practice of a profession in its licensure law — that is, the description range of activities in which licensed members of the profession may legally engage. Legislated scopes of practice are usually quite broad and general. The subset(s) of activities within a profession’s scope of practice in which each individual licensed professional can engage ethically depends on the specific education and training that individual has completed — that is, their scope of competence. This is stated explicitly in the regulations for most LMHPs (including LPCs and LCSWs).
Neither scope of practice for LPC or LCSW includes behavior analysis according to the licensure laws in VA. Both refer to the principles and methods of those respective professions, which differ substantially from the principles and methods of behavior analysis. The task lists resulting from recent job analysis studies for counseling and social work include little or nothing on behavior analysis. Therefore, the same is true of the coursework, experiential training, and licensure exams in those professions.
In short, the practice of behavior analysis is not in the scope of practice of either of those professions, so even if some individual LPCs or LCSWs in VA claim to have some training and experience in behavior analysis, they don’t meet the criterion in the “Exceptions” section of our behavior analyst licensure law.
For more information, it is important to note the definitions of the healthcare provider taxonomy codes for Behavior Analyst, Counselor, and Social Worker that have been issued by the AMA's National Uniform Claims Committee: https://npidb.org/taxonomy/
Q. Is RBT (Registered Behavior Technician) required for Behavior Technicians?
A. No. Virginia does not require it and neither does DMAS. The LBA or LABA is ultimately responsible for the technician’s actions.
Q. In Northern VA, we often use behavior technicians for parent training because of language barriers (in that the technician can speak the family’s language). How can we manage this if parent training isn’t reimbursable for the technician level?
A. See DMAS’s language and disability access plan for help with this: https://www.dmas.virginia.gov/media/3536/2021-dmas-language-and-disability-access-plan.pdf
Providers are required in their enrollment agreement to be responsible for translation. Providers cannot bill for translation work or to have an extra person there to translate. Any expansion of billing that is currently in place will require GA authority.
4.15 TRANSLATION & INTERPRETER SERVICES Translation services (including oral interpreter services and sign language interpreter services) shall be available to ensure effective communication regarding treatment, consent to treatment, medical history, or health education. [42 CFR § 438.10(c)(4)] Trained professionals, including qualified sign language interpreters, shall be used when needed where technical, medical, or treatment information is to be discussed with the Member, a family Member or a friend. The Contractor shall institute a mechanism for all Members who do not speak English to communicate effectively with their PCPs and with Contractor staff and subcontractors. If five hundred (500) or more of its Members are non-English speaking and speak a common language, the Contractor shall include, if feasible, in its network at least two (2) medically trained professionals who speak that language. In addition, the Contractor shall provide TTY/TDD services for the hearing impaired.
Q. Do individuals need a diagnosis of autism spectrum disorder in order to receive ABA services reimbursed by Medicaid?
A. No. The eligibility requirements are not changing.
Q. Can individuals over the age of 21 access over ABA services after 12/1?
A. No, the service still falls under EPSDT. Some individuals over 21 are able to access behavior analysts through Therapeutic Consultation.
Q. Will there be a new authorization form specifically for the ABA service?
A. Yes, that is currently being created and will be posted here around the second week of November 2022: https://dmas.virginia.gov/for-providers/behavioral-health/
Q. Are both a 30-day and quarterly review required?
A. Yes, but the 30 calendar day ISP review requirements can be met through a progress note that clearly documents the following: the treatment plan, including goals and progress towards them has been discussed with the team and the individual; any alterations to the ISP; the review and any necessary changes have been discussed with the individual and the individual’s response. The individual’s signature is not required.
Q. How much family treatment is needed each week?
A. Direct family involvement in the treatment program is required at a minimum of weekly but the amount of direct interaction with the treatment provider will vary according to the clinical necessity, progress as documented, and the youth and family goals in the ISP. Family involvement includes, but is not limited to, assessment, family training, family observation during treatment, updating family members on the youth’s progress and involving the family in updating treatment goals. This is billable by LABA and LBA staff. (97156)
Q. With what services can and cannot ABA be authorized simultaneously?
Services cannot be authorized concurrently with Intensive In-Home, Mental Health Skill Building, Psychosocial Rehabilitation, Partial Hospitalization Program or Assertive
Community Treatment.
Services can be authorized concurrently with Multisystemic Therapy, Functional Family Therapy, Therapeutic Day Treatment, Counseling (not an exhaustive list).
Q. Is a letter of necessity from a physician still required?
A. No. An order or letter recommending services signed by a physician, nurse practitioner or physician assistant who is the child’s primary care provider or another provider familiar with the developmental history and current status of the child is no longer necessary for services. However, the LBA, LABA or LMHP must notify the primary care physician that the child is receiving ABA services.
Q, If a member has primary insurance (commercial through employer) and Medicaid as secondary, should the provider get two authorizations or just one through the primary?
For members in Fee-for-Service a service auth is required and Magellan is clear in their provider guidance documents concerning this.
As for the MCOs, the health plans have a choice, and DMAS's recommendation would be to reach out to the plans about this. Here is anecdotal information, but again providers need to confirm this when they are starting services with an individual:
Auth Required:
Aetna: not sure
Anthem: No
Molina: No
Optima: Yes
United: No
VAP: Yes
Q. What signatures are needed and when do they need to be obtained?
Chapter VI: page 17:
“All ISPs shall be completed, signed, and contemporaneously dated by the allowed professional for the service (as detailed in Chapters II and IV and the Appendices to this manual) who prepares the ISP within a maximum of 30 calendar days from the date of initiation of services unless otherwise specified. The youth’s ISP shall also be signed by the parent/legal guardian, as appropriate, and the adult individual shall sign his own. If the individual, whether a youth or an adult, is unwilling to sign the ISP, then the service provider shall document the clinical or other reasons why the individual was not able or willing to sign the ISP. Signatures shall be obtained unless there is a medical or clinical reason that renders the individual unable to sign the
Chapter VI: page 20
Progress Note Documentation
“Providers shall be required to maintain progress notes detailing all relevant information about the Medicaid individuals who are in providers' care. Such documentation shall fully disclose the extent of services provided in order to support providers' claims for reimbursement for services rendered. Progress notes shall support the medical necessity criteria and how the individual’s needs for the service match the level of care criteria. This documentation shall be written, signed, and dated at the time the services are rendered or within one business day from the time the services were rendered.”
Q. How do I become a Medicaid Provider?
There are three entities that are involved in reimbursing providers for services to Medicaid Members:
1. The Department of Medical Assistance Services (DMAS)
2. The Behavioral Health Services Administrator (BHSA) – Magellan
3. The Managed Care Organizations (MCOs) – Aetna Better Health, Anthem Healthkeepers Plus, Molina, Optima, United Healthcare, Virginia Premier
To become a provider, you first register with the BHSA/DMAS through the Medicaid Enterprise System (MES) – Home | MES (virginia.gov). Unfortunately, the Center for Medicaid and Medicare Services (CMS – a federal organization) has instituted a one-time fee for new providers of $631. We are working on getting funding to cover that, but for now, providers will need to pay the fee to register.
Once registered through the MES, you need to have each LBA credentialed and contracted with each MCO for whom you are going to accept patients (you can choose one or all six).
Note that to bill for RBTs or LABAs, you must have an organizational NPI number.
Billing
Q. For authorizations, we are seeing one code, 97155 with a bank of hours. Just to clarify, we will bill the appropriate codes when services are rendered but not to exceed the total number of 97155 units in the current authorization?
A. Yes, this is correct. Providers should bill using the appropriate CPT codes for the service delivered. The ISP must reflect the type and frequency of treatment interventions.
Ongoing, MCOs will authorize a number of units in 97155, but providers should still bill the correct codes. For more information, see page 7 of the DMAS FAQ: https://dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf
Q. Will ABA be reimbursable if provided in a school?
A. Many members have been asking questions about Medicaid and ABA in Schools. Here is some clarification. Please email admin@virginiaaba.org if you have any questions.
Q. Where are the billing rates posted?
A. The rates can be found here: https://www.magellanofvirginia.com/media/6530/dmas_-aba-final-rate-assumptions-log_101421.pdf
Q. Do the billing rates posted on 10/15 include the 12.5% increase that goes into effect from December 2021 to June 2022?
A. No. That increase is in addition.
Q. Can 97155 and 97153 be billed concurrently?
A. Yes. However, the LABA modifier cannot be billed for both codes simultaneously. In addition, 97152 may be billed at the same time as 97151 (with the exception of 97152 HN together with 97151 HN); 97153 may be billed at the same time as 97155 (with the exception of 97153 HN together with 97155 HN); and 97154 and 97158 may be billed at the same time for different youth in the same group (professional level modifier must be identical).
Q. Why is the rate for Group Treatment (97154) higher for LABAs than it is for LBAs?
A. It is because it includes the supervision time for the LBA.
Q. Will the Medically Unlikely Edits (MUEs) be in place for 97151 in that no more than 2 hours can be billed in a single day?
A. No. MUEs won’t be applied to 97151.
Q. Can you please clarify the monthly and weekly documentation requirements that are considered non-billable?
A. That will be best explained in the manual which will be posted here around the second week of November 2021: https://dmas.virginia.gov/for-providers/behavioral-health/
Q. Can an LBA bill while still in the credentialing process with the MCO?
A. Yes. A law was passed in 2020 that says: “A carrier that credentials the physicians, mental health professionals, or other providers in its network shall establish reasonable protocols and procedures for reimbursing new provider applicants, within 30 days of being credentialed by the carrier, for health care services or mental health services provided to covered persons during the period in which the applicant's completed credentialing application is pending.” See the bill here: https://lis.virginia.gov/cgi-bin/legp604.exe?201+ful+HB822ER
Q. Will the 8-minute rounding rule be used for these services?
A. Information about the 8-minute rounding rule can be found here, however DMAS has stated that no rounding up will be allowed with any behavioral health service. In the Behavioral Therapy Manual it stated, “Providers shall not 'round up' for Behavioral Therapy Services. One service unit equals 15 minutes for this level of care. Providers shall not round up for partial units of service. Providers may accumulate partial units throughout the week for allowable span billing, however, shall bill only whole units. Time billed shall match the documented time rendering the service in the member’s clinical record and in accordance with DMAS requirements.”
Q. Will requests for specific codes need to be included in the initial authorization?
A. No, you will request the time needed and then will be free to use it among the codes as is clinically necessary.
Q. Do I use a Group or Individual NPI number for billing?
A. This is very tricky so it's best to check your contract and with the MCO.
From what we've been told, for 97155, you could use an Individual Provider NPI. For 97153 and codes that involve someone other than the LBA delivering services, it depends on the MCO. Optima, Molina, and UHC require organizational NPIs for those codes; Magellan, Virginia Premiere, and Aetna do not have this requirement; unsure for Anthem at this time.
Q. Was the 12.5% increase approved in 2022?
A. Yes!
And MCOs should be reprocessing any claims that were denied for the increase by September.
This increase should be approved ongoing.
Further Billing Guidance from DMAS
Click here for an FAQ on billing guidance from DMAS.
Assessments
Q. Will assessments need to be pre-authorized in the future?
A. No, that process should remain the same. Codes 97151, 97152, and 0362T do not need pre-authorization.
Q: Do assessments require all 15 components of the CNA?
Yes. Please refer to the manual for more information.
Q. Can baseline data be collected from parent report?
A. Yes. Baseline data should be collected from whatever sources you have in the assessment. If later you find that you have more accurate information, you can update the baseline as appropriate.
Q. Are there specific assessments that need to be used?
A. Unlike TRICARE and some private insurances, Medicaid does not require specific branded assessments. It will be necessary to provide all the information requested in the manual, but it is up to the clinical judgement of the QHP as to what assessments are used.
Q. What about reassessments?
A. Reassessments should also be billed under 97151 (see page 42 #7 of the 11/30/21 manual – that number is referring to periodic reassessments and NOT standard data analysis and protocol modification). DO NOT get an authorization for reassessments. Just bill as you would the initial assessment.
Care Coordination
Q. Care coordination is something that is relied heavily upon with this service for Medicaid members, but is not as common with other payors and therefore probably won’t be accounted for in the rate study. Will there be a separate code for Case Coordination so that it can be billed directly?
A. Yes. When the manual was posted on 11/22, it listed 97155 as the code for care coordination, when the activities meet certain elements in the code description “non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.”
Here is additional billing guidance:
-Care coordination, data analysis and treatment plan preparation activities provided by the LBA, LMHP or LABA without the youth present may be billed under 97151 at the time of the initial assessment and reassessments.
-To bill for time spent by the QHP to review data, modify the treatment protocol and provide additional care coordination as part of ongoing assessments, the QHP must bill under 97155.
Care coordination is a larger system issue for DMAS (beyond just ABA), so there will most likely be changes in the future as Project BRAVO takes shape.
Q. Will Technicians be allowed to bill for Care Coordination?
A. No. 97151 is for LBAs and LABAs.
Telemedicine/Telehealth
Q. What is the difference between telemedicine and telehealth?
A. That is defined in the telehealth services supplement.
Telehealth: Telehealth means the use of telecommunications and information technology to provide access to medical and behavioral health assessment, diagnosis, intervention, consultation, supervision, and information across distance. Telehealth encompasses telemedicine as well as a broader umbrella of services that includes the use of such technologies as telephones, interactive and secure medical tablets, remote patient monitoring devices, and store-and-forward devices. Telehealth includes services delivered in the dental health setting (i.e., teledentistry), and telehealth policies for dentistry are covered in the dental manuals.
Telemedicine: Telemedicine is a means of providing services through the use of two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine does not include an audio-only telephone.
Q. Will ABA services be allowed through telemedicine?
A. Yes. A telemedicine manual was posted at the same time as the ABA manual for public comment. In the new manual, the originating site was changed to include the home of an individual receiving services. According to that manual, ABA can be provided via telemedicine including codes 97151-8, 0362T, 0373T when certain conditions are met and the supervising LBA deems the modality to be the best clinical decision for the patient. For more information, see that manual (https://dmas.virginia.gov/for-providers/behavioral-health/regulations-provider-manual/). Also seek information about HIPAA and information privacy.
Q. Can the initial assessment be performed via telehealth?
A. Only as long as we are in a Public Health Emergency as determined by the governor. https://www.governor.virginia.gov/ However, initial assessments are meant to be performed face-to-face.
Q. Does telemedicine face-to-face need to be two way? In other words, if the supervisor can see the client, but the supervisor’s face is distracting to the client, so the supervisor’s camera is turned off, is it still a billable service?
A. This is being explored and an answer will be provided at a later date.