CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A
Autism Spectrum Disorders Mandate (Payment Policy)
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Defines BCBSRI coverage and requirements for Autism Spectrum Disorders services (including ABA, PT, OT, speech, behavioral health) for Commercial Products in accordance with Rhode Island law; affects members whose plans are subject to the RI mandate and participating providers.
Policy Summary
PayerBlue Cross Blue Shield - Rhode Island
PolicyAutism Spectrum Disorders Mandate (Payment Policy)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 1, 2026
Last ReviewJun 1, 2026
Next Review DateApr 15, 2026
Key ActionInsurer may require submission of a treatment plan signed by an appropriate child specialist; updated plan may be required no more frequently than quarterly.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
CommercialApplies to
ABA, PT, OT, speechCovered types
No age limit notedAge restriction
15 minTime unit
97110/97112Common CPTs
Coverage Criteria and Scope
Commercial Products coverage criteria
Coverage for Autism Services under Commercial Products and statutory requirements per R.I. General Law 27-20.11.
Services covered for treatment of Autism Spectrum Disorders (ASD) under Commercial Products include: Applied Behavioral Analysis (ABA) services, pharmaceuticals, physical therapy (PT), speech therapy, psychology, psychiatry, and occupational therapy (OT).
ABA services must be provided and/or supervised by a state-licensed individual: (a) a Licensed Applied Behavior Analyst; or (b) a Licensed Applied Behavior Assistant Analyst under the supervision of a Licensed Applied Behavior Analyst; or (c) a psychologist with equivalent ABA experience or practicing within their scope of practice.
Benefits apply only to services delivered within the State of Rhode Island unless preauthorization demonstrates the required services are not available in-state, in which case out-of-state coverage is required.
Although R.I. General Law states benefits continue until the covered individual reaches age 15, BCBSRI notes it does not impose an age restriction for Autism Services in this policy.
For plans or self-funded groups that do not adopt the Rhode Island Autism mandate, ABA and related behavioral interventions may be a contract exclusion; refer to specific member agreements for coverage applicability.
Carrier may require submission of medical records to substantiate initial or continued medical necessity; treatment may be required to demonstrate continued improvement and members may appeal denials per applicable rules.
Coverage and billing rules (partial)
Covered services and billing rules in this excerpt
Physical therapy, occupational therapy, and speech therapy codes listed in this policy are covered and are excluded from any service limits or prior authorization requirements when submitted with a primary diagnosis of autism (F84.0, F84.5, F84.8, F84.9).
If a PT/OT/speech provider is certified as an ABA provider and renders ABA services, the provider must use the specific ABA CPT/Category III codes in the coding section to report those ABA services.
Coverage of Autism Services does not alter obligations of school districts under IDEA; services furnished by school personnel are not benefits under this policy.
For utilization management or questions regarding coverage, contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958.
CPT code listing (no coverage rules in these chunks)
This section enumerates billable CPT codes and their descriptors used in the Autism Spectrum Disorders mandate payment policy for Commercial Products. No explicit coverage limits, prior authorization, or exclusion statements are present in these chunks.
Examples of listed therapeutic modality/procedure codes (each unit = 15 minutes)
- 97033 — iontophoresis, each 15 minutes
- 97034 — contrast baths, each 15 minutes
- 97035 — ultrasound, each 15 minutes
- 97036 — Hubbard tank, each 15 minutes
- 97110 — therapeutic exercises, each 15 minutes
- 97112 — neuromuscular reeducation, each 15 minutes
- 97113 — aquatic therapy, each 15 minutes
- 97116 — gait training, each 15 minutes
- 97124 — massage, each 15 minutes
- 97139 — unlisted therapeutic procedure (specify), each 15 minutes
Therapeutic activities and self-care codes (time-based)
- 97530 — therapeutic activities, direct one-on-one, each 15 minutes
- 97535 — self-care/home management training (ADL), each 15 minutes
- 97537 — community/work reintegration training, each 15 minutes
- 97140 — manual therapy techniques, each 15 minutes
- 97150 — group therapeutic procedures (2+ individuals), each 15 minutes
Most listed CPT codes in these sections are described and billed in 15-minute units; see coding sections for the full code list and descriptors.
Listed codes (informational)
Codes and descriptors included in this policy segment (no explicit coverage conditions provided here).
Repeatedly referenced procedure codes (15-minute units)
Descriptions in these chunks emphasize the 15-minute unitization and group vs individual distinctions where applicable.
Referenced CPT codes
Codes referenced in this portion of the policy that relate to therapeutic services for ASD-related care.
No explicit coverage decisions, visit limits, or prior authorization criteria for these individual CPT entries are provided within these chunks; refer to coverage sections for medical necessity and benefit applicability.
Coding/coverage listing
Codes and service descriptors appearing in this document segment
Coverage criteria — not present in excerpt
No explicit coverage criteria or medical necessity rules are included in this segment; only CPT codes and brief descriptors appear.
This excerpt contains repeated lists of CPT codes and brief descriptors without accompanying authorization or medical necessity criteria; refer to other sections of the policy for coverage determinations and requirements.
Listed procedure codes
Codes and time-based reporting described in this excerpt (no explicit clinical coverage criteria stated here).
Commonly listed procedure codes (each 15 minutes)
- 97113 — aquatic therapy with therapeutic exercises
- 97116 — gait training (includes stair climbing)
- 97124 — massage (effleurage, petrissage, tapotement)
- 97139 — unlisted therapeutic procedure (specify)
- 97140 — manual therapy techniques
- 97150 — group therapeutic procedures
- 97530 — therapeutic activities, one-on-one
- 97535 — self-care/home management training (ADL), one-on-one
All codes in these listings are repeatedly shown with 15-minute unitization; billing must follow the specified time unit conventions.
Coding references only
Codes and billing units referenced in this section
Service code listing
Code mappings and descriptors (no explicit authorization or exclusion criteria in this fragment).
These chunks emphasize functional examples (e.g., shopping, transportation, meal preparation, ADL training) tied to the appropriate CPT codes used for therapeutic and community/work reintegration services.
Listed therapy services
Codes and service descriptions referenced for ASD-related therapeutic services (no explicit coverage rules in this excerpt).
Providers should refer to the coding section for complete descriptors and to member-specific benefit documents to confirm coverage and limits.
Therapy service codes (reference)
Service descriptors and associated CPT codes (time unit = each 15 minutes):
Therapy service codes referenced
- 97139 — Unlisted therapeutic procedure (specify)
- 97140 — Manual therapy techniques, per 15 minutes
- 97150 — Group therapeutic procedure, per 15 minutes
- 97530 — Therapeutic activities, one-on-one, per 15 minutes
- 97535 — Self-care/home management training (ADL), per 15 minutes
- 97537 — Community/work reintegration training, per 15 minutes
Refer to the policy's coverage criteria and the member's subscriber agreement for determinations of medical necessity, benefit eligibility, and any applicable limits. Providers may not charge members for non-covered services unless the member is informed and agrees in writing.
Coverage summary
The document lists covered CPT procedures for therapeutic services; actual coverage and payment depend on member benefits and medical necessity.
Coverage of ABA, PT, OT, speech and related services is governed by the member's subscriber agreement/employer agreement and by medical necessity; benefits listed in this policy are informational and subject to plan terms.
BCBSRI may require submission of a treatment plan (frequency and duration) signed by an appropriate clinician (e.g., child psychiatrist, behavioral developmental pediatrician, child neurologist, or licensed psychologist with child training); updated plans may be required no more frequently than quarterly.
Providers should verify member eligibility and benefit coverage with BCBSRI prior to rendering services and contact the provider call center or Behavioral Health Utilization Management for member-specific information.
Codes and Billing Rules
Covered ABA-related codes when rendered by certified ABA providerCPTCovered
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by a physician or other qualified HCP on site; with assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment customized to the patient's behavior. |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by a physician or other qualified HCP on site; with assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment customized to the patient's behavior. |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of professional time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face activities such as analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. |
ABA assessment and treatment codesCPTCovered
| 0362T | Behavior identification supporting assessment, each 15 minutes (technician) |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes (technician) |
| 97151 | Behavior identification assessment by physician/qualified HCP, each 15 minutes |
| 97152 | Behavior identification-supporting assessment by technician, each 15 minutes |
| 97153 | Adaptive behavior treatment by protocol, administered by technician, each 15 minutes |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients, each 15 minutes |
| 97155 | Adaptive behavior treatment with protocol modification, administered by a physician or qualified HCP, may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or qualified HCP, face-to-face with guardian(s)/caregiver(s), each 15 minutes |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or qualified HCP, face-to-face with multiple sets of guardians/caregivers, each 15 minutes |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by a physician or qualified HCP, face-to-face with multiple patients, each 15 minutes |
Codes not to be used for ABA; file with applicable Category I/III codes insteadCPT | HCPCSNot Covered
| H0031 | Mental health assessment by non-physician (NOT to be used) |
| H0032 | Mental health service plan development by non-physician (NOT to be used) |
| H2019 | Therapeutic behavioral services, per 15 minutes (NOT to be used) |
| H2012 | Behavioral health day treatment, per hour (NOT to be used) |
| H2014 | Skills training and development, per 15 minutes (NOT to be used) |
PT/OT/ST and related therapy codesCPTCovered
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Treatment of speech, language, voice, communication; group (two or more individuals) |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification |
| 97129 | Therapeutic interventions focusing on cognitive function, direct (one-on-one) patient contact; initial 15 minutes |
| 97161 | Physical therapy evaluation: low complexity |
| 97162 | Physical therapy evaluation: moderate complexity |
| 97163 | Physical therapy evaluation: high complexity |
| 97164 | Physical therapy re-evaluation (not separately reimbursed) |
| 97165 | Occupational therapy evaluation, low complexity |
1–10 of 13
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Therapeutic modality and procedure CPTsCPTCovered
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (unattended), each 15 minutes |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception |
| 97113 | Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) |
| 97124 | Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage |
Therapeutic procedure and modality CPTsCPTCovered
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes |
| 97110 | Therapeutic exercises to develop strength and endurance, range of motion and flexibility; 15 minutes |
| 97112 | Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception; 15 minutes |
| 97113 | Aquatic therapy with therapeutic exercises; 15 minutes |
| 97116 | Gait training (includes stair climbing); 15 minutes |
| 97124 | Massage, including effleurage, petrissage and/or tapotement; 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
Therapy CPT codes referencedCPTCovered
| 97110 | Therapeutic exercises to develop strength and endurance, range of motion and flexibility; 15 minutes |
| 97112 | Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception; 15 minutes |
| 97113 | Aquatic therapy with therapeutic exercises; 15 minutes |
| 97116 | Gait training (includes stair climbing); 15 minutes |
| 97124 | Massage, including effleurage, petrissage and/or tapotement; 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction); per 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97036 | Hubbard tank modality, each 15 minutes |
Therapy/rehab procedure codes (covered or referenced)CPT
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes |
| 97113 | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals), 15-minute units |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes |
Therapeutic procedure and activity CPT codesCPTCovered
| 97112 | Neuromuscular re-education; listed repeatedly |
| 97113 | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one, each 15 minutes |
| 97535 | Self-care/home management training (ADL and compensatory training), each 15 minutes |
Therapy and therapeutic activity CPT codesCPTCovered
| 97113 | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, including effleurage, petrissage and/or tapotement, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), each 15 minutes |
| 97150 | Therapeutic procedures, group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one, each 15 minutes |
| 97535 | Self-care/home management training, each 15 minutes |
Therapeutic and self-care CPT codesCPTCovered
| 97113 | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one, each 15 minutes |
| 97535 | Self-care/home management training, each 15 minutes |
Therapeutic CPT codes referencedCPTCovered
| 97113 | Aquatic therapy with therapeutic exercises, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, including effleurage, petrissage and/or tapotement, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one, each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one, each 15 minutes |
| 97537 | Community/work reintegration training, each 15 minutes |
Therapeutic procedure CPT codes referencedCPTCovered
| 97537 | Community/work reintegration training; direct one-on-one contact, each 15 minutes |
| 97116 | Gait training (includes stair climbing), each 15 minutes |
| 97124 | Massage, each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one, each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one, each 15 minutes |
ASD-related therapy codesCPTCovered
| 97124 | Therapeutic procedure, 1 or more areas; massage (effleurage, petrissage and/or tapotement), each 15 minutes |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one patient contact, each 15 minutes |
| 97535 | Self-care/home management training (ADL and compensatory training, meal preparation, safety procedures, and assistive technology instruction), direct one-on-one, each 15 minutes |
| 97537 | Community/work reintegration training (shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology), each 15 minutes |
OT/PT and related therapy codesCPT
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, 1 or more regions, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one patient contact, each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one contact, each 15 minutes |
| 97537 | Community/work reintegration training, direct one-on-one contact, each 15 minutes |
Therapy and related procedure codesCPTCovered
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques, 1 or more regions, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) |
| 97530 | Therapeutic activities, direct one-on-one patient contact, each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one contact, each 15 minutes |
| 97537 | Community/work reintegration training, direct one-on-one contact, each 15 minutes |
Geographic delivery
Geographic scopeBenefits apply only to services delivered within the State of Rhode Island; out-of-state coverage may be provided if preauthorization establishes the required services are not available in-state.
Preauthorization conditionOut-of-state services require preauthorization showing in-state providers in the carrier's network cannot provide required services.
ApplicabilityApplies to services covered under the Rhode Island ASD mandate and BCBSRI Commercial Products.
Prior authorization requirement for PT/OT/ST when autism is primary diagnosis
Prior authorization exceptionPT/OT/ST codes submitted with a primary diagnosis of Autism (F84.0, F84.5, F84.8, F84.9) are covered and excluded from any service limits or prior authorization requirements.
Relevant CPTsIncludes speech, PT and OT codes such as 92507, 92508, 92526, 92609, 97129, 97161–97168 when autism is primary diagnosis.
Parity noteVisit limits applicable to PT/OT/speech for other conditions do not apply when provided as treatment for ASD (per MHPAEA and state mandate).
Time unit
Default time unitMost listed CPT procedures are reported per 15-minute unit.
Examples of time-based codesIncludes modality and therapeutic procedure codes such as 97033, 97034, 97035, 97036, 97110, 97112 billed per 15 minutes.
Billing implicationWhen submitting claims for these CPTs, report units in 15‑minute increments as indicated in code descriptors.
time_unit
Standard unitizationTherapeutic activities (97530) and related procedure codes are billed in 15-minute units.
Group vs individualGroup procedures (97150) and individual therapeutic activities (97530) both reference 15-minute reporting units.
Claim reportingReport number of 15-minute units for each session element per CPT code guidance.
Time unit
15-minute reportingMultiple therapeutic procedure and self-care codes (e.g., 97113, 97116, 97124, 97140, 97535) are specified per 15 minutes.
Self-care training unitization97535 (self-care/home management training) is described as direct one-on-one contact, each 15 minutes.
Manual therapy unitizationManual therapy (97140) is reported per 15 minutes for one or more regions.
time_unit
15-minute unit (general)The policy repeatedly specifies a 15-minute unit for listed therapeutic and modality CPT codes.
Repeated code examplesCodes such as 97124, 97139, 97140, 97150, 97530, 97535 and 97537 are shown with 15-minute unitization across chunks.
Provider billing noteEnsure unit counts reflect actual 15-minute increments of face-to-face time per code.
Provider Responsibilities and Billing Guidance
Prior Authorization
Submit signed treatment plan on request
Insurer may require submission of a treatment plan that includes frequency and duration of treatment, signed by a child psychiatrist, behavioral developmental pediatrician, child neurologist, or a licensed psychologist with training in child psychology; an updated treatment plan may be required no more frequently than quarterly.
Documentation Required
Contact Behavioral Health UM
For questions about utilization review, providers should contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958.
Documentation Required
PT/OT/ST services excluded from limits when primary dx = autism
When PT/OT/ST codes are submitted with a primary diagnosis of autism (F84.0, F84.5, F84.8, F84.9), those codes are covered and excluded from any service limits or prior authorization requirements.
Billing Rule
Listed CPT modality & procedure descriptions (15-minute units)
The policy lists CPT codes and brief descriptors for therapeutic modalities and procedures (examples include 97033 iontophoresis each 15 minutes; 97034 contrast baths each 15 minutes; 97035 ultrasound each 15 minutes; 97036 Hubbard tank each 15 minutes; 97110 therapeutic exercises each 15 minutes; 97112 neuromuscular reeducation each 15 minutes; 97113 aquatic therapy each 15 minutes; 97116 gait training each 15 minutes; 97124 massage each 15 minutes).
- 97033 — iontophoresis, each 15 minutes
- 97034 — contrast baths, each 15 minutes
- 97035 — ultrasound, each 15 minutes
- 97036 — Hubbard tank, each 15 minutes
- 97110 — therapeutic exercises, each 15 minutes
- 97112 — neuromuscular reeducation, each 15 minutes
- 97113 — aquatic therapy with therapeutic exercises, each 15 minutes
- 97116 — gait training (includes stair climbing), each 15 minutes
- 97124 — massage (effleurage, petrissage and/or tapotement), each 15 minutes
Documentation Required
CPT codes and descriptors — billing reference (15-minute unitization)
The document repeatedly lists CPTs used for modalities and therapeutic procedures and specifies each as reported per 15-minute unit (examples: 97035 ultrasound; 97036 Hubbard tank; 97110, 97112, 97113, 97116, 97124; 97139 unlisted therapeutic procedure).
Documentation Required
Therapeutic CPT codes and short descriptors
Therapeutic CPT procedure codes are listed with brief descriptors and 15-minute unitization; examples include therapeutic exercises (97110), neuromuscular reeducation (97112), aquatic therapy (97113), gait training (97116), massage (97124), manual therapy (97140), group therapy (97150), and unlisted therapeutic procedure (97139).
- 97110 — therapeutic exercises, each 15 minutes
- 97112 — neuromuscular reeducation, each 15 minutes
- 97113 — aquatic therapy with therapeutic exercises, each 15 minutes
- 97116 — gait training (includes stair climbing), each 15 minutes
- 97124 — massage, each 15 minutes
- 97139 — unlisted therapeutic procedure (specify), each 15 minutes
- 97140 — manual therapy techniques, each 15 minutes
- 97150 — therapeutic procedure(s), group (2+ individuals), per 15 minutes
Documentation Required
CPT code list — therapy procedures (individual & group, time-based)
Multiple therapy procedure CPT codes are enumerated for ASD-related services and are described as time-based (15-minute units), including both individual and group procedures (examples shown in the policy).
Billing Rule
Therapeutic procedure codes & descriptors (group vs individual; 15-min units)
The policy lists commonly used therapeutic procedure CPTs for ASD-related care (examples: 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97535) and reiterates that these are reported in 15-minute units with distinctions between group and individual services.
- 97112 — neuromuscular reeducation, per 15 minutes
- 97113 — aquatic therapy, per 15 minutes
- 97116 — gait training, per 15 minutes
- 97124 — massage, per 15 minutes
- 97139 — unlisted therapeutic procedure (specify), per 15 minutes
- 97140 — manual therapy techniques, per 15 minutes
- 97150 — group therapeutic procedures, per 15 minutes
- 97530 — therapeutic activities, per 15 minutes
- 97535 — self-care/home management training, per 15 minutes
Note
No authorization rules stated in excerpt
This excerpt does not specify prior authorization rules or numeric authorization thresholds for the listed CPTs; authorization requirements are not stated in the provided text.
Documentation Required
Therapeutic services CPT list — reference
The policy repeats a comprehensive list of therapeutic services and CPTs used in ASD-related care (e.g., 97116, 97124, 97139, 97140, 97150, 97530, 97535, 97537) and directs providers to use those CPTs when reporting services.
- 97116 — gait training, each 15 minutes
- 97124 — massage, each 15 minutes
- 97139 — unlisted therapeutic procedure (specify), each 15 minutes
- 97140 — manual therapy techniques, each 15 minutes
- 97150 — group therapeutic procedures, each 15 minutes
- 97530 — therapeutic activities, each 15 minutes
- 97535 — self-care/home management training, each 15 minutes
- 97537 — community/work reintegration training, each 15 minutes
Documentation Required
CPT code list — therapeutic procedures (examples)
Examples of therapeutic procedures and mappings used in the ASD mandate include community/work reintegration (97537), therapeutic activities (97530), self-care/home management training (97535), manual therapy (97140), unlisted therapeutic procedure (97139), and group therapy (97150); all are listed with 15-minute reporting.
- 97537 — community/work reintegration training, each 15 minutes
- 97530 — therapeutic activities, each 15 minutes
- 97535 — self-care/home management training, each 15 minutes
- 97140 — manual therapy techniques, each 15 minutes
- 97139 — unlisted therapeutic procedure (specify), each 15 minutes
- 97150 — group therapeutic procedures, each 15 minutes
Documentation Required
Therapy CPT codes and unitization (15-minute rule reiterated)
Therapy CPTs and unitization are reiterated across the policy: manual therapy (97140), unlisted therapeutic procedure (97139), group procedures (97150), therapeutic activities (97530), self-care training (97535), and community/work reintegration (97537) are all described as each 15 minutes.
Documentation Required
Therapy CPT code references — use listed CPTs and confirm eligibility
The policy references therapy CPTs for reporting ASD-related services and repeatedly lists the codes providers should use for therapeutic modalities and activities (examples: 97139, 97140, 97150, 97530, 97535, 97537); refer to those CPTs when coding services.
Billing Rule
Confirm member eligibility and billing rules before charging
Benefits and eligibility are determined by the member's subscriber agreement or employer agreement; for member-specific benefits contact the provider call center. Providers may not charge members for services determined to be not medically necessary or non-covered unless the member was informed and agreed in writing.
Definitions and Code Notes
Applied Behavioral Analysis (ABA)
DefinitionApplied Behavioral Analysis (ABA) is the systematic design, implementation, and evaluation of behavioral modification plans using learning theory to produce socially significant behavioral improvement.
Treatment goalsGoals include teaching new skills, increasing/maintaining behaviors, generalization, and reducing interfering behaviors.
Delivery formatIntensive behavioral intervention often involves highly structured, one-to-one therapist-delivered techniques.
Autism Spectrum Disorders (ASD)
DefinitionAutism Spectrum Disorders (ASD) means any of the pervasive developmental disorders as defined by the most recent DSM edition.
Services coveredScope includes ABA, physical therapy, speech therapy, and occupational therapy for treatment of ASD under the Rhode Island mandate.
Age provisionState statute continues benefits until age 15, but BCBSRI notes it does not impose an age restriction for Autism Services.
certified ABA provider
Certified ABA providerABA codes are covered when rendered by a certified ABA provider in accordance with R.I. Gen. Law 27-20.11; certain Category III codes require specified administration and staffing.
Credential requirementsSome Category III services (0362T, 0373T) require administration by a physician or qualified HCP on site with the assistance of two or more technicians.
Filing guidanceProviders should file ABA services with the applicable Category I and III CPT codes rather than H0031/H0032/H2019/H2012/H2014.
F84.0, F84.5, F84.8, F84.9
ICD-10 codesF84.0, F84.5, F84.8, F84.9 are referenced as primary Autism diagnoses for which PT/OT/ST codes are covered and excluded from limits/prior auth.
Use caseWhen one of these codes is the primary diagnosis on the claim, specified therapy CPTs are exempt from service limits and prior authorization.
ScopeApplies to Physical Therapy, Occupational Therapy, and Speech Therapy services submitted with the primary diagnosis of ASD.
97112
97112 description97112 — Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception; billed per 15 minutes.
Typical useUsed for therapies addressing balance, coordination and functional movement during sessions billed in 15-minute units.
ReportingReport number of 15‑minute units of 97112 corresponding to face‑to‑face time performed.
97113
97112 (repeated)97112 is consistently listed as a 15-minute therapeutic procedure for neuromuscular reeducation.
97112 billingBilled per 15-minute unit as part of the therapy CPT group in this policy.
ContextAppears alongside other modality codes (97033–97036, 97110, 97113, 97116, 97124) using 15‑minute unitization.
15-minute time unit
Time unit standardPolicy specifies a 15-minute time unit for many therapeutic CPTs; report units accordingly.
ExamplesCodes such as 97035, 97036, 97110, 97112, 97113, 97116, 97124 are given with 'each 15 minutes' descriptors.
Claim submissionUnits should reflect actual face-to-face 15-minute increments for each CPT billed.
97139 (Unlisted therapeutic procedure)
97139 classification97139 — Unlisted therapeutic procedure (specify) is included among therapeutic CPTs in the policy.
When to useUse 97139 when no specific CPT code appropriately describes the therapeutic service; documentation must specify the procedure.
Context in policy97139 appears repeatedly alongside other time‑based therapeutic procedure codes.
Therapeutic procedure CPT codes (15-minute units)
Therapeutic CPTs time-basedMultiple therapeutic procedure CPT codes (e.g., 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97535, 97537) are described with 15-minute unitization.
Billing guidanceReport each code in 15‑minute units where indicated by the code descriptor and policy text.
ScopeCodes cover therapeutic exercises, neuromuscular reeducation, aquatic therapy, gait training, massage, manual therapy, group procedures, therapeutic activities, and self-care training.
97530
97530 definition97530 — Therapeutic activities: direct (one-on-one) patient contact using dynamic activities to improve functional performance; each 15 minutes.
Typical applicationUsed for individualized functional training and dynamic activities to improve performance; bill per 15-minute unit.
Relation to other codesOften billed alongside self-care (97535) and manual therapy (97140) as clinically indicated.
97150
97150 description97150 — Therapeutic procedure(s), group: procedures provided to two or more individuals; units reported in 15-minute increments.
Group definitionGroup procedures are defined as services provided to 2 or more individuals.
Billing noteReport 15-minute units for group sessions using 97150 as appropriate.
group (2 or more individuals)
Group therapyGroup therapeutic procedures (97150) are for two or more individuals and are billed per 15-minute unit.
Contrast with individualIndividual therapeutic activities (97530) are direct one-on-one contacts, billed per 15 minutes.
Use caseSelect group vs individual CPT based on the number of participants and service provided.
direct (one-on-one) patient contact using dynamic activities to improve functional performance
Direct patient contactTherapeutic activities (97530) represent direct one-on-one patient contact using dynamic activities to improve functional performance.
UnitizationReported in 15‑minute increments per policy code descriptors.
Clinical roleUsed to address functional deficits through targeted, dynamic activities during therapy sessions.
97535 (e.g., activities of daily living and compensatory training)
97535 definition97535 — Self-care/home management training: activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in assistive technology; direct one-on-one, each 15 minutes.
Typical activitiesIncludes ADL training, compensatory strategies, meal prep, safety and assistive device instruction.
BillingReport per 15-minute unit for one-on-one self-care/home management training sessions.
97535
97535 repeated97535 is repeatedly listed as self-care/home management training billed in 15-minute units.
Clinical examplesMeal preparation, safety procedures, ADL and compensatory training delivered one-on-one.
DocumentationEnsure documentation supports ADL training components and time billed per 15-minute unit.
97530
97530 (repeated)97530 — Therapeutic activities (direct one-on-one), each 15 minutes; used to improve functional performance.
Relation to other codesOften billed with 97140 (manual therapy) and 97535 (self-care) as clinically indicated.
Billing practiceDocument dynamic activities performed and report units in 15-minute increments.
Self-care/home management training (97113 / 97535)
Self-care/home management training codesSelf-care/home management training is represented by 97113/97535 and includes ADL and compensatory training; billed per 15 minutes.
Clinical componentsMay include meal prep, safety procedures, assistive device instruction, and compensatory strategies.
DocumentationRecord ADL components and face-to-face time to substantiate 15-minute units billed.
Manual therapy / therapeutic procedures (97140, 97150)
Manual therapy codesManual therapy techniques and related therapeutic procedures are represented by codes such as 97140 and 97150 and are reported per 15 minutes.
ExamplesManual techniques include mobilization/manipulation, manual lymphatic drainage, and manual traction.
Billing noteDocument region(s) treated and time to support 15‑minute units billed for manual therapy.
Therapeutic activities
Therapeutic activities definitionTherapeutic activities use dynamic activities to improve functional performance; billed per 15 minutes (97530).
Use casesMay address balance, coordination, posture, and functional task performance during one-on-one sessions.
DocumentationList specific activities performed and time to justify billed units.
Self-care/home management training
Self-care/home management training summarySelf-care/home management training (97535) targets ADLs and compensatory training; billed per 15 minutes for direct one-on-one contact.
ExamplesMeal preparation, safety procedures, assistive technology instruction and compensatory strategies.
Relation to ASD careUsed to improve daily living skills for individuals with ASD as part of therapy plans.
Group therapy
Group therapy (97150)Group therapeutic procedures (97150) are provided to two or more individuals and billed in 15-minute units.
Service distinctionGroup sessions should be billed under 97150 when two or more patients are treated together.
DocumentationRecord attendance and time per participant to support billed group units.
Therapeutic activities
Therapeutic activities (97530)Direct one-on-one patient contact using dynamic activities to improve functional performance; billed per 15 minutes.
Clinical examplesBalance and coordination tasks, kinesthetic and posture activities performed during therapy.
Billing guidanceUnits reflect actual 15-minute increments of direct face-to-face therapeutic activity.
Self-care/home management training
Self-care/home management training (97535)97535 covers ADL and compensatory training, meal prep, safety procedures, and assistive device instruction; direct one-on-one, each 15 minutes.
Clinical relevanceUsed to teach daily living skills to individuals with ASD and related needs.
Billing/documentationDocument ADL goals, activities performed, and time to support units billed.
Therapeutic procedure, 1 or more areas, each 15 minutes; massage
Therapeutic procedure descriptor97124 — Therapeutic procedure, 1 or more areas, each 15 minutes; massage (effleurage, petrissage and/or tapotement) is listed in the policy.
Clinical useMassage techniques used as part of therapeutic treatment and reported in 15‑minute units.
DocumentationSpecify regions treated, modality, and time to support billed units.
Self-care/home management training (97535)
97535 reiterated97535 is consistently listed as Self-care/home management training billed in 15-minute increments and applied to ADL/compensatory training.
Service examplesMeal preparation, safety procedures, assistive device instruction included in 97535 context.
Billing practiceEnsure sessions and time are documented to match 15-minute units billed.
Self-care/home management training (97535)
97535 usageSelf-care/home management training (97535) applies to ADL and compensatory training delivered one-on-one, billed per 15 minutes.
Clinical componentsIncludes meal prep, safety, assistive technology instruction and compensatory strategies.
Documentation requirementDocument specific ADL tasks and face-to-face time to justify units billed.
Therapeutic activities (97530)
97530 therapeutic activities97530 represents therapeutic activities (direct one-on-one) to improve functional performance; billed per 15 minutes.
Typical interventionsDynamic activities focused on functional tasks, balance, coordination, and kinesthetic training.
Billing noteRecord activities and time in 15-minute increments for claim support.
Community/work reintegration training (97537)
97537 definition97537 — Community/work reintegration training: activities such as shopping, transportation, money management, avocational activities and/or work environment/task analysis; billed per 15 minutes.
Use caseApplied to community and work reintegration skills training for direct one-on-one sessions.
DocumentationDocument tasks trained, patient participation, and time per 15-minute unit.
Manual therapy (97140)
97140 manual therapy97140 — Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), per 15 minutes; used for one or more regions.
Clinical examplesMobilization, traction and manual lymphatic drainage applied and billed per 15 minutes.
Documentation guidanceRecord techniques used, regions treated and time to support billed units.
Unlisted therapeutic procedure (97139)
97139 unlisted use97139 — Unlisted therapeutic procedure (specify) is included for services not described by a specific CPT code; documentation must describe the procedure.
When applicableUse when a provided therapeutic procedure lacks an appropriate CPT code; include supporting description for adjudication.
Policy placement97139 is repeatedly listed alongside other time‑based therapeutic CPTs in the policy.
Group therapeutic procedures (97150)
97150 group procedures97150 — Group therapeutic procedures for 2 or more individuals; units reported in 15-minute increments.
Billing distinctionUse 97150 for group sessions; individual therapeutic activities use codes like 97530 or 97535.
DocumentationList participants and time to support billed group units.
Community/work reintegration training (97537)
97537 community/work training97537 covers community/work reintegration training; billed per 15 minutes for direct one-on-one contact.
Activities includedShopping, transportation, money management, avocational activities and work environment/task analysis.
Billing supportDocument community tasks practiced and time to justify 15-minute units billed.
Self-care/home management training (97535)
97535 self-care97535 — Self-care/home management training: ADL and compensatory training billed per 15 minutes; used for direct one-on-one interventions.
ExamplesMeal prep, safety procedures, assistive device instruction and compensatory strategies.
Documentation expectationDocument specific ADL tasks, goals, and time for each 15-minute unit billed.
Level of Care / Setting Guidance
Outpatient / Intensive behavioral intervention (one-to-one therapy)
Intensive behavioral intervention involves highly structured, one‑to‑one ABA techniques and the clinical goals used to justify medical necessity.
Admission criteria: Intensive behavioral intervention (one‑to‑one ABA) is appropriate when a patient with ASD exhibits deficits in social communication/interaction and/or behaviors that substantially impair functioning and when ABA is intended to teach new skills, increase or maintain selected behaviors, generalize skills, or reduce interfering behaviors (e.g., aggression, self-injury).
Provider qualifications: ABA must be delivered or supervised by appropriately licensed and credentialed providers (Licensed Applied Behavior Analyst, Licensed ABA Assistant under supervision, or psychologist with equivalent ABA experience) and, when applicable, by a certified ABA provider for the Category I/III ABA codes listed in the coding section.
Documentation required: A treatment plan describing goals, target behaviors, frequency, duration, and measurable objectives should be maintained; the carrier may request records to support initial or continued medical necessity and may require periodic updates as described elsewhere in the policy.
Continued stay criteria: Continued ABA services should demonstrate ongoing clinical progress toward documented objectives; lack of measurable improvement may prompt review and documentation to justify continued treatment.
Applied Behavior Analysis (ABA) Specifics
ABA clinical description
Codes and required service components for certain ABA Category III codes and behavior identification services.
Behavior identification and technician-driven Category III codes (0362T, 0373T) require administration by a physician or other qualified health care professional who is on site, with the assistance of two or more technicians, provided in a customized environment for patients exhibiting destructive behavior.
Therapies and Modalities
Speech/Feeding therapy
Speech, feeding, PT/OT coverage rules and exception when autism is primary diagnosis.
When PT/OT or speech therapy is provided for treatment of ASD and billed with a primary diagnosis of autism (F84.0, F84.5, F84.8, F84.9), the listed PT/OT/ST CPT codes are covered and excluded from any service limits or prior authorization requirements.
Services provided by school personnel are not benefits under this policy and the coverage does not alter school district obligations under federal or state special education laws.
Therapeutic/rehabilitation procedures
Therapeutic and rehabilitation procedures commonly used in ASD care (time unit: each 15 minutes).
Therapeutic/rehabilitation procedures (examples)
These modalities and procedures are billed in 15‑minute increments; providers must follow the coding and time unit conventions in the coding section when submitting claims.
Therapeutic/rehabilitation procedures
Occupational/Physical therapy modalities and functional activity codes used to address ADLs and community reintegration.
Community/work reintegration training (97537) covers tasks such as shopping, transportation, money management, and work environment analysis; billed per 15 minutes.
Visit limits and time units
Visit limits and time unit conventions relevant to Autism Services in this excerpt.
BCBSRI does not specify numeric age or visit limits in this excerpt; R.I. statute states benefits continue until age 15 but BCBSRI indicates no age restriction in policy.
The majority of therapeutic and ABA-related CPT codes referenced in this policy are billed in 15‑minute units; providers must report time-based services in the indicated increments.
PT/OT/ST codes billed with a primary diagnosis of autism are excluded from service limits and prior authorization requirements for groups that offer Autism Services.
Visit Limits and Unitization
ABA / PT / OT / Speech — no limits specified
No numeric limits specifiedBCBSRI policy excerpt does not specify age or visit limits for ABA, PT, OT, or speech services; coverage subject to member benefits and medical necessity.
Statutory age vs policyState statute continues benefits until age 15, but BCBSRI notes it does not impose an age restriction for Autism Services.
Member-specific determinationActual benefits and any limits depend on the member's subscriber or employer agreement and medical necessity.
PT/OT/ST codes when primary diagnosis is autism (F84.x)
Excluded from limitsPT/OT/ST codes submitted with a primary diagnosis of Autism (F84.x) are covered and excluded from any service limits or prior authorization requirements.
Relevant diagnosesApplies when primary diagnosis is F84.0, F84.5, F84.8 or F84.9.
Impact on utilization managementThese services should not be subject to prior authorization or visit limits when billed for ASD as primary diagnosis.
No visit limits specified in this segment
Visit limits not specifiedThis policy segment lists CPTs with 15-minute unitization but does not specify numeric visit limits.
Unit-based billingTherapy services are described time‑based (15‑minute units) rather than by visit counts.
Clinical authorizationContinued medical necessity and documentation support may be required even if numeric visit limits are not listed.
Multiple therapy CPTs listed with 15-minute unitization; no numeric visit limits specified
15-minute unitization across codesMultiple therapy CPTs (e.g., 97113, 97116, 97124, 97140, 97530, 97535) are consistently described as billed per 15-minute unit.
No numeric visit capsPolicy repeats time-based unitization but does not list numeric per-period visit caps in the excerpt.
Provider documentationProviders should document face-to-face time and clinical necessity to support billed 15‑minute units.
97113, 97116, 97124, 97140, 97530, 97535 — per 15-minute unit
Codes billed per 15 minutes97113, 97116, 97124, 97140, 97530, 97535 are listed and described as reported per 15-minute unit.
Service typesIncludes aquatic therapy, gait training, massage, manual therapy, therapeutic activities and self-care training.
Claim submissionReport units for these CPTs in 15-minute increments consistent with the policy descriptors.
listed CPT therapeutic and self-care procedures — time-based (15 minute unit)
Therapeutic/self-care time-based listThe policy repeatedly lists therapeutic and self-care CPTs as time-based with 15-minute units (e.g., 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97535, 97537).
Billing implicationProviders should adhere to 15-minute unit reporting and maintain documentation supporting time billed.
No per-member limits shownThis excerpt contains no numeric per-member visit or hour limits for these codes.
Multiple CPT codes referenced as each 15 minutes
Multiple codes time-basedMultiple CPT codes in the policy are repeatedly specified as each 15 minutes (e.g., 97113, 97116, 97530, 97535, 97537).
Consistent unitizationConsistent 15-minute billing applies across individual, group, manual, and community reintegration CPTs listed.
Documentation expectationDocument activities, participants, and face-to-face time to justify 15-minute units billed.
Multiple codes specify 15-minute billing units
15-minute billing units emphasizedThe policy emphasizes 15-minute billing units for many therapeutic CPTs (e.g., 97530, 97535, 97537) across the document.
Claims guidanceEnsure unit counts match actual 15-minute increments of direct face-to-face service per CPT.
No numeric visit caps in excerptAlthough time-based units are specified, the excerpt does not set numeric visit limits per period.
Policy Summary
PayerBlue Cross Blue Shield - Rhode Island
PolicyAutism Spectrum Disorders Mandate (Payment Policy)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 1, 2026
Last ReviewJun 1, 2026
Next Review DateApr 15, 2026
Key ActionInsurer may require submission of a treatment plan signed by an appropriate child specialist; updated plan may be required no more frequently than quarterly.
SourceLink
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