ABA Parent/Caregiver Guidance via Telemedicine Extended
Tuesday, June 9, 2020
In March, the Defense Health Agency (DHA) expanded telemedicine options under TRICARE’s Autism Care Demonstration (ACD) to allow applied behavior analysis (ABA) parent/caregiver guidance via telehealth. This policy exception, originally effective March 31–May 31, 2020, has now been extended through the end of the national COVID-19 health emergency period. Find current benefit information on our Applied Behavior Analysis benefit detail page.
Parent/caregiver guidance – CPT® 97156. TRICARE is temporarily allowing ABA supervisors (BCBA-Ds, LBAs, BCBAs) and assistant behavior analysts (BCaBAs, QASPs) to render Current Procedural Terminology (CPT®) code 97156 services via synchronous (two-way, video) telehealth. (Behavior technicians cannot render 97156 services.) HNFS will perform audits to ensure compliance with these guidelines. All session note and medical documentation requirements must still be met.
Audio-only telehealth and relaxed state licensing excluded from ACD. Although TRICARE is temporarily allowing for audio-only telehealth in response to COVID-19, audio-only services are not allowed under the ACD. Parent/caregiver guidance billed under 97156 must be rendered using audio AND video platforms. Similarly, while TRICARE has relaxed state professional licensing requirements during the national health emergency period, these revised guidelines do not apply to the ACD. ABA providers are authorized under a demonstration authority, not the 32 Code of Federal Regulations, 199.6. As such, ABA providers must continue to comply with telemedicine guidelines outlined in TRICARE Policy Manual, Chapter 7, Section 22.1.
Same-day telehealth and direct care. Services billed under CPT codes 97151, 97153 and 97155 remain prohibited for delivery via telehealth (see TRICARE Operations Manual, Chapter 18, Section 4). Services under 97156 can still be rendered in person, but direct services billed under 97153, 97155 or 97156 are not reimbursable when rendered on the same day as a 97156 telehealth visit.
Initial assessments. ABA providers may perform approved initial assessments (97151) via indirect methods (not telehealth) for patients they are unable to meet with in person. Program modifications (97155) can be made once direct visits start. Reassessments (97151) can also be completed indirectly for beneficiaries whose authorizations are expiring. ABA supervisors may need to estimate progress from the last direct visit if services have been suspended or are only via telehealth. ABA supervisors should continue to complete reassessments and update treatment plans on the normal timeline.
Authorizations. No changes are required for existing authorizations. All other requirements for reauthorization (referrals, PDD-BI, treatment plans) are still mandatory, without exception. Do not let authorizations lapse! Continue to submit reauthorization requests 30 days prior to current authorizations expiring, even if care is not being rendered. We are unable to issue retroactive authorizations for ABA services, including 97156 via telehealth.
Billing. Claims for 97156 telehealth visits must include the GT modifier and place of service 02. This service is unlimited during this emergency period; however, there must be an approved authorization on file for 97156 for claims to pay.
Telehealth copayment waiver. TRICARE is waiving copayments and cost-shares for covered telemedicine rendered by network providers on or after May 12, 2020. This waiver is allowed for the ACD. It applies to covered in-network telehealth services, not just services related to COVID-19.
For TRICARE updates related to COVID-19, visit our COVID-19 resources page and www.tricare.mil/coronavirus.
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