Applied Behavior Analysis (ABA) proposed fee schedule for Medicaid Fee-for-Service
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Proposed ABA fee schedule and code crosswalk for New Mexico Medicaid fee-for-service, specifying codes, modifiers, allowed practitioners, unit definitions, prior authorization requirements, and proposed rates (subject to public comment). Affects providers billing ABA services to New Mexico Medicaid FFS recipients.
Modifier U9 (practitioner new to the fee schedule, a Board Certified Assistant Behavioral Analyst) is being newly added to the ABA fee schedule.
Several CPT/HCPCS codes used in 2018 (0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T) are replaced by standard CPT codes (e.g., 97151, 97152, 97153) with new unit definitions (15-minute units) and adjusted rates for 2019.
Comprehensive Diagnostic Evaluation (CDE) T1026 and ISP development/updates remain at $130.00 per hour with Prior Auth: NO and CDE frequency guidance (every 36 months or sooner if warranted).
Stage 3 implementation and supervision codes (T1026 with modifiers UC/UD and U3-U5/U9) require prior authorization for clinical management and direct/indirect case supervision; supervision ratio rules specified (at least 1 hour clinical management per 10 hours of Stage 3; more than 2 hours per 10 hours requires prior authorization).
0374T is no longer valid for dates of service after December 31, 2018.
Coverage criteria and billing scope for ABA services
Coverage criteria for ABA services
Covered when ALL of the following apply:
Coverage and billing criteria
Coverage and billing rules (summary of proposed fee-schedule criteria):
Proposed coverage and billing rules
Operational billing notes and proposed procedural rules:
Code crosswalks, unit definitions, and billing units
| 97151 | Behavior Identification Assessment (replaces 0359T); unit = 15 minutes |
| 97152 | Behavior Identification Supporting Assessment (replaces 0360T/0361T/0362T variants); unit = 15 minutes |
| 97153 | Adaptive Behavior Treatment by Protocol (replaces 0364T/0365T variants); unit = 15 minutes |
| T1026 | Comprehensive Diagnostic Evaluation / ISP / Stage 3 clinical management and supervision (hourly-based entries present) |
| 97153 | Adaptive Behavior Treatment by Protocol; 1 unit = 15 minutes (replaces 0364T/0365T) |
| 97154 | Group Adaptive Behavior Treatment by Protocol; 1 unit = 15 minutes (replaces 0366T/0367T) |
| 97155 | Protocol modification with recipient present; 1 unit = 15 minutes (replaces 0368T/0369T) |
| 97158 | Adaptive Behavior Treatment Social Skill Group; 1 unit = 15 minutes (replaces 0372T) |
| 0373T | Adaptive Behavior Treatment with Protocol Modification requiring 2+ BTs/BAAs; remains valid with revised units (1 unit = 15 minutes) |
| 0373T | Adaptive Behavior Treatment with Protocol Modification; referenced as retained/modified code with new unitization (15-minute units and 60-minute first unit). |
| 0374T | Previously used for additional 30 minutes; indicated as no longer valid for dates of service after 2018-12-31 and to be replaced by 0373T. |
Prior authorization, supervision, and provider obligations
Prior authorization and supervision rules for Stage 3
Stage 3 clinical management and case supervision require prior authorization for certain entries. At least 1 hour of clinical management or case supervision is required per 10 hours of Stage 3 services; more than 2 hours per 10 hours of Stage 3 services requires prior authorization. If a full 60 minutes is not provided in one day, bill a partial unit using decimal points and aggregate across days as appropriate.
- Prior Auth: YES for Stage 3 clinical management (T1026 entries with modifier UC) and for specified direct/indirect case supervision entries.
- Minimum supervision ratio: 1 hour clinical management/case supervision per 10 hours of Stage 3 services.
- When supervision exceeds 2 hours per 10 hours of Stage 3 services, obtain prior authorization.
- Partial 60-minute units may be billed using decimal points when a full hour is not provided in a single day.
CDE/ISP prior authorization, frequency, and unit limits
Comprehensive Diagnostic Evaluation (CDE) and ISP development/updates (T1026) do not require prior authorization. CDE is to be performed every 36 months or sooner if medically warranted, and a CDE is limited to a maximum of 10 one-hour units.
- Prior Auth: NO for CDE (T1026) and ISP Update entries.
- CDE frequency: every 36 months or sooner if medically warranted.
- Unit limit: Maximum of 10 one-hour units per CDE.
- Rate reference: $130.00 per hour for CDE/ISP entries as listed.
Prior authorization required for many ABA codes
Many ABA procedure codes listed in the proposed fee schedule are marked as requiring prior authorization; several replacement CPT entries (for example 97153 and related Stage 3 codes) include Prior Auth: YES in their notes.
- Prior Auth: YES is indicated for multiple ABA codes in the fee schedule (e.g., entries replacing 0364T/0365T mapped to 97153 show Prior Auth: YES).
- The new modifier U9 is added alongside some of these codes; the fee schedule notes that U2 is removed and U1 will serve the bachelor's-level designation.
Prior authorization for unit definitions and initial 60-minute entries
Prior authorization is required for certain unit definitions and for initial 60-minute billing entries (e.g., 0373T initial 60-minute unit and the 15-minute unitized entries), and the fee schedule instructs billing of partial units using decimal points when a full interval is not provided in a single day.
- 0373T (initial 60 minutes) — Prior Auth: YES and use for first hour of service; bill partial hours using decimal points.
- Unitized 1 unit = 15 minutes entries for codes replacing 03xxT are noted with Prior Auth: YES where indicated in the schedule.
- 0374T is no longer valid for dates of service after 12/31/2018; use 0373T instead (Prior Auth: YES applies to the replacement entries).
Key terms, modifiers, and practitioner roles
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