SUPPLEMENTAL GUIDANCE ON INTERPRETING AND APPLYING THE 2019 CPT CODES FOR ADAPTIVE BEHAVIOR SERVICES
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CLINICAL EXAMPLE:
Prior to the appointment, the qualied health care professional (QHP) reviews the child’s medical records,
previous assessments, and records of any previous or current treatments. Just before the assessment
session, the QHP gathers all materials required for that session.
During the session (face-to-face), the QHP conducts a structured interview with the parents to solicit their
observations about the child’s decient adaptive behaviors (e.g., social, communication, or self-care skills),
maladaptive behaviors, and other concerns. The QHP conducts a series of indirect and direct assessments to
identify potential skills to be strengthened and maladaptive behaviors to be reduced by treatment.
Indirect assessments include standardized and non-standardized scales and checklists completed by the
parents and other caregivers to evaluate the patient’s adaptive skills in several domains. Direct assessments
of adaptive skills include direct observation and recording of the child’s performance of skills in typical
everyday situations, including information about the type and amount of assistance (cues, prompts) the child
requires to perform each skill successfully and the types of reinforcers for which the child responds. Direct
assessments of maladaptive behaviors include a functional behavior assessment comprising an interview with
the parents about environmental events that may precede and follow occurrences of maladaptive behaviors,
and observations of the child in several everyday settings to record occurrences of tantrums, repetitive
movements, and other maladaptive behaviors as well as environmental events that precede and follow those
occurrences. Information from the functional behavior assessment is used to design functional analyses of
tantrums and ritualistic behaviors. These assessments may be conducted over several days of service.
After: The data from all assessments are used to develop a treatment plan with goals and objectives, including
social, communication, play and leisure, self-care, and other skills to be developed and maladaptive
behaviors to be reduced, all dened in observable, measurable terms. The plan also species for each
treatment target: (a) the current (baseline) level; (b) procedures for direct observation and measurement; (c)
conditions under which the behavior is to occur; (d) a written protocol with instructions for implementing
procedures (e.g., materials needed, instructions, prompting and prompt-fading, consequences for correct
and incorrect responses, etc.) to change the behavior and promote generalization of behavior changes; and
(e) criteria for mastery or attainment of the treatment goal.
Q: Is 97151 intended to be used for day-to-day assessment and treatment planning?
A: No. This code is intended for reporting initial assessment and treatment plan development and reassessment
and progress reporting by the QHP (timeframes for reassessments are determined by payer policy or medical
necessity). 97151 includes face-to-face time with the patient and/or caregivers to conduct assessments as well as
non-face-to-face time for reviewing records, scoring and interpreting assessments, and writing the treatment plan
or progress report. The QHP must have conducted both the face-to-face and non-face-to-face activities to report
this service. Day-to-day assessment and treatment planning by the QHP are bundled into the treatment codes
below (i.e., 97153-97158 and 0373T); therefore, 97151 cannot be used to report those indirect services because
they do not meet all requirements of the code descriptor.
Q: Why does 97151 include non-face-to-face work and the other codes in the 2019 set do not?
A: Assessments and reassessments require extensive non-face-to-face time for the QHP to score assessments,
review records and data, and write or update the treatment plan. That can take several hours, and in many cases
occurs across multiple dates of service. That is why only this code allows for reporting of non-face-to-face time.