97154 CPT code Description

A Guide to 97154 CPT Code Description 2023

“Adaptive Behavior Treatment Procedures” is the category under which code 97154 falls. There are some similarities between this code and other codes used in the same method covered in this guide.
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As we all know, medical billing plays a crucial role in maintaining the satisfaction of patients, accurate documentation, financial stability, and insurance requirements. This becomes possible when correct Current Procedural Terminology (CPT) codes are utilized.

“Adaptive Behavior Treatment Procedures” is the category under which code 97154 falls. There are some similarities between this code and other codes used in the same method covered in this guide. This article includes all the details and particular recommendations.

Also read: CPT code 97152 Description

What are CPT codes used to represent?

To process claims, conduct research, assess healthcare utilization, and create medical guidelines and other types of healthcare documentation, the most widely recognized medical terminology is provided by the CPT descriptive terminology and its associated code numbers. With these codes, medical professionals can more accurately and efficiently classify medical services and procedures, simplify reporting, and improve efficiency.

Understanding CPT Code 97154

“Adaptive Behavior” refers to the skills and behaviors individuals use to function and adapt daily. These procedures are therapeutic interventions aimed at helping individuals improve their adaptive skills. They are typically utilized in the treatment of individuals with developmental disabilities, autism spectrum disorder, or other conditions that impact their day-to-day functioning.

97154 is used for a type of therapy administered by a technician under the supervision of a physician or other qualified healthcare professional. It involves face-to-face sessions with two or more patients, each lasting 15 minutes.

The specific nature of the procedures falling under CPT code 97154 can vary, as they encompass a range of therapeutic techniques and interventions customized to address individual needs. These may include teaching and shaping behaviors, skill development, behavior management techniques, and strategies to enhance independence and functional skills.

Is pre-authorization required for CPT code 97154?

It depends on the insurance company and the specific plan. Some insurance plans may require pre-authorization for CPT code 97154, while others may not. It is important to check with the insurance company or the healthcare provider to confirm whether pre-authorization is required.

Note: Even if pre-authorization is not initially required, insurance companies may conduct retrospective reviews or audits to ensure that the services provided were medically necessary and complied with their policies.

What are the required documents for billing 97154?

The required documents for billing code 97154, which is used for the procedure, must include:

  • Detailed description of the services provided

This document should clearly outline the nature of the therapy or intervention provided to the patient. It should specify the type of treatment, techniques used, and the goals of the therapy session.

  • Date of service

This is simply the date when the therapy session took place. It’s important for accurate billing and record-keeping.

  • Duration of the therapy session

This indicates the length of time the therapy session lasted, typically in minutes. It’s crucial for determining the appropriate billing rate and ensuring accurate reimbursement.

  • Credentials of the therapist providing the service

This document should confirm the qualifications and credentials of the healthcare provider or therapist who administered the therapy. It helps in establishing the legitimacy of the service and is often required for insurance and billing purposes.

What are the Modifiers for CPT Code 97154?

  1. -U1 (Habilitation)

This modifier shows how habilitation services, which assist individuals in acquiring skills necessary for everyday living and functioning, are connected to adaptive behavior treatment.

  1. -U2 (Rehabilitation)

Adaptive behavior treatment is associated with rehabilitation services, which concentrate on restoring lost abilities or relearning skills following an illness or accident, according to this modification.

  1. -25 (Significant, Separately Identifiable E/M Service)

When adaptive behavior treatment is administered on the same day as an Evaluation and Management (E/M) service, such as a medical examination, this modifier is applied. The therapy and the E/M service should be invoiced separately because they are distinct.

  1. -59 (Distinct Procedural Service)

When adaptive behavior treatment is combined with another procedure on the same day, it is denoted by the -59 modifier. It ensures correct remuneration and helps in the prevention of service bundling.

Difference between CPT codes 97153 and 97154

CPT code 97153 represents “Group Adaptive Behavior Therapy” and involves therapeutic interventions conducted in a group setting, focusing on improving adaptive behavior skills among individuals with developmental disabilities. CPT code 97154, on the other hand, is a broader code for “Adaptive Behavior Treatment Procedures” that includes both individual and group therapy.

It encompasses various therapeutic techniques and interventions to address adaptive behavior skills and functional outcomes in individuals with developmental disabilities or related conditions.

Insurance of CPT Code 97154

Most healthcare providers are curious whether a given CPT code is insured. The specific insurance plan and the medical necessity of the service will determine whether or not CPT Code 97154 is covered by insurance.

Suppose the medical care is considered medically vital and is rendered by a healthcare professional who is in-network with the patient’s insurance plan. In that case, insurance companies may cover it.

It’s important to verify with the patient’s insurance provider to understand their unique policy and any pre-authorization or documentation requirements, as coverage and reimbursement rates can vary.

Conclusion

The abilities and actions people use to get by and adjust to their daily surroundings are called “adaptive behavior,” its billing is best treated with the help of the code 97154. It is necessary to ensure effective and standardized treatment approaches, promote accountability, and support the ongoing development and improvement of adaptive behavior treatment procedures.

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