What is CPT code 97152 description and reimbursement?

97152 CPT code by the American Medical Association, 97152, is used “Under Adaptive Behavior Assessment Procedures.”

97152 CPT code by the American Medical Association, 97152, is used “Under Adaptive Behavior Assessment Procedures.” It offers a standardized framework for assessing an individual’s adaptable abilities and behaviors, enabling specialists to collect comprehensive and unbiased data. For this reason, it is very helpful in adaptive behavior assessment methods.

We have compiled descriptive information covering the essential information about it.

What does CPT 97152 codeĀ  mean?

During direct patient interaction, a technician under the supervision of a physician or other competent healthcare professional provides a supporting assessment of a patient’s destructive behavior and behavioral issues. This code is reported for each 15 minutes the technician spends in person with the patient.

What are the requirements for billing 97151 CPT code?

When billing for CPT code 97152, there are several requirements and considerations to keep in mind:

  • Documentation

Proper documentation is crucial for billing CPT code 97152. This should include detailed assessment records, the assessment tools or instruments used, and the assessment results. This documentation should support the medical necessity of the assessment.

  • Licensed Provider

The service must be provided by a licensed healthcare professional qualified to conduct adaptive behavior assessments. This may include psychologists, board-certified behavior analysts (BCBAs), or other qualified professionals, depending on state regulations.

  • Medical Necessity

The assessment must be medically necessary, meaning it is required to evaluate the individual’s adaptive behavior and develop an appropriate treatment plan. The assessment should be ordered based on the patient’s specific needs.

  • Time

It typically represents the first 30 minutes of adaptive behavior assessment procedures. If the assessment takes longer, additional time may be billed using the appropriate CPT codes.

  • Code Usage:

Ensure that the code is used accurately and reflects the specific services provided during the assessment. Accurate coding is important for reimbursement and compliance.

  • Insurance Verification

Verify with the patient’s insurance provider if the code is a covered service under their plan. Different insurance companies may have varying policies regarding coverage for adaptive behavior assessment procedures.

  • Proper Modifiers

Depending on the circumstances, you may need to use modifiers to provide additional information about the services or circumstances of the assessment. Consult with your billing department or coding guidelines for appropriate modifiers to use.

What are the advantages of CPT 97152?

When billed properly, this code may provide several benefits in the favor of the patient as well as the medical professional who is dealing with the process.

  1. Standardized Billing

CPT codes provide a standardized method for billing and reporting healthcare services, ensuring that the healthcare provider is reimbursed appropriately for their services.

  1. Documentation and Tracking

By using CPT code 97152, healthcare providers can document and track the services they provide in the assessment of adaptive behavior, which is important for maintaining accurate patient records and for assessing the progress of individuals over time.

  1. Insurance Reimbursement

Using specific CPT codes, including 97152, facilitates the processing of insurance claims, making it easier for patients to receive reimbursement for assessment services.

  1. Regulatory Compliance

Properly coding services using CPT codes helps healthcare providers adhere to regulatory and compliance requirements, reducing the risk of audits and ensuring that services are billed appropriately.

  1. Consistency

CPT codes provide a consistent language for healthcare professionals, insurance companies, and government agencies, ensuring clarity and uniformity in the reporting and billing of healthcare services.

  1. Reimbursement Transparency

CPT codes often have associated reimbursement rates, which can help healthcare providers and patients understand the potential costs and reimbursement amounts for adaptive behavior assessments.

  1. Research and Data Analysis

The use of CPT codes like 97152 allows for easier data collection and analysis of adaptive behavior assessment services, which can be valuable for research, outcome measurement, and quality improvement efforts.

What are the risks and challenges

While the CPT code doesn’t inherently involve risks and challenges, the risks and challenges associated with using this code typically relate to medical billing, coding, and documentation. Here are some potential risks and challenges:

  1. Reimbursement Issues

Billing for services using CPT codes involves dealing with insurance companies and government payers. The reimbursement rate can vary, and providers may encounter delays or denials in reimbursement, leading to financial challenges.

  1. Evolving Regulations

The healthcare industry is subject to changing regulations and coding updates. Staying up-to-date with the latest changes in CPT codes and associated rules can take time and effort.

  1. Patient Consent

Depending on the nature of the test or measurement, obtaining informed consent from the patient may be necessary. Failure to secure proper consent can lead to legal and ethical challenges.

  1. Privacy and Security

Handling patient information, including reports related to tests and measurements, requires strict adherence to patient privacy regulations (e.g., HIPAA in the United States). Breaches of patient privacy can result in legal and reputational issues.

  1. Billing Errors

Errors in medical billing can lead to financial losses for healthcare providers. It’s important to have robust billing processes to minimize the risk of errors.

How is 97151 different from 97152?

Here’s the difference between these two CPT codes:

CPT code 97151: “Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with a written report, every 15 minutes.”

This code describes the performance of various physical tests or measurements, typically related to a patient’s musculoskeletal or functional capacity. It may include assessments like range of motion testing, strength testing, or available capacity evaluations. A written report is typically generated as part of this service.

CPT code 97152: “Wheelchair management (e.g., assessment, fitting, training), every 15 minutes.”

It describes the assessment, fitting, and training related to wheelchair management for a patient. It typically involves assessing the patient’s needs for a wheelchair, fitting them for the appropriate wheelchair, and providing training on how to use and manage the wheelchair effectively.

What is the modifier for the 97152 code?

Modifier – 25

This modifier means that the same medical professional or qualified healthcare worker did a significant evaluation and management (E/M) service on the same day as a procedure or another service. This means the E/M service differed from the procedure and should be billed separately.

Modifier – 59

If a service was different from other services offered on the same day, the 59 prefix is used to indicate that. When more than one procedure is done at the same visit, the 59 modifier is added to the CPT code of the second treatment to show that it is a separate service.

Modifier – 52

The 52 modifier indicates that a service was partially reduced or eliminated at the physician’s discretion. This modifier is typically applied when a procedure is not performed in its entirety for a specific reason, such as a complication or a patient’s tolerance. It signifies that the service was modified or reduced in some way.

Other Modifiers

Modifier U1 and U2

U1 and U2 are typically used with CPT/HCPCS codes. These two modifiers indicate that a qualified healthcare professional performs the service provided under the general supervision of a medical professional or other qualified healthcare professional.

Can CPT 97152 be used for telehealth services?

CPT code 97152 is not eligible for telehealth services as it requires direct one-on-one contact between the provider and the patient. To conduct a 97152 assessment via telehealth, the technician must be face-to-face (in-person or via telehealth) with the patient, or the payer must allow the caregiver to serve as a proxy for the technician.

Is 97152 Insured?

The insurance coverage for CPT code 97152 may differ depending on the specific insurance plan and policy. It is suggested to contact your insurance provider directly to confirm the coverage for this CPT code.

Remember that insurance coverage can change over time, so it’s always a good idea to double-check with your insurance provider to ensure that the services associated with this CPT code are covered.


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