2025 CPT code 97153
(Active) Effective Date: N/A Revision Date: N/A Medicine Services and Procedures - Adaptive Behavior Services Medicine Feed
Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, per 15 minutes.
Modifiers may be appended to indicate the involvement of a higher-level provider.Specific modifier selection depends on the payer's guidelines and circumstances.
Medical necessity for 97153 is established through a comprehensive assessment demonstrating the patient's need for adaptive behavior treatment.The treatment plan should define specific, measurable, achievable, relevant, and time-bound (SMART) goals and outline how the services address the patient's diagnosed condition or impairment.Documentation must justify the intensity and frequency of therapy.
The supervising physician or qualified healthcare professional is responsible for designing the treatment protocol, overseeing the technician's implementation, and ensuring the patient's progress. The technician, under the direction of the qualified professional, carries out the prescribed protocol and documents the session.Both are responsible for ensuring appropriate documentation and adherence to relevant coding guidelines.
In simple words: This code covers one-on-one therapy sessions led by a trained technician, overseen by a doctor or other qualified professional, to help improve a patient's behavior. The therapy follows a set plan, and the code is billed for each 15-minute session.
CPT code 97153 represents adaptive behavior treatment delivered according to a pre-established protocol by a technician under the supervision of a physician or qualified healthcare professional.The service is provided face-to-face with a single patient and is billed in 15-minute increments.The protocol is designed in advance by the physician or qualified professional, who may or may not provide direct supervision during the session. This code is used for direct one-on-one Applied Behavior Analysis (ABA) therapy sessions.
Example 1: A child diagnosed with Autism Spectrum Disorder (ASD) receives one-on-one ABA therapy from an RBT. The RBT implements a pre-designed protocol focusing on improving the child's communication skills.The supervising BCBA is present for part of the session to offer guidance and observe the treatment., An adult with intellectual disabilities participates in a 45-minute session (3 units of 97153) with an RBT focused on improving daily living skills. The supervising occupational therapist is not present during the entire session but reviews progress notes., A patient with a traumatic brain injury undergoes intensive therapy to relearn self-care skills. An RBT, under the guidance of a physical therapist, implements a structured protocol focusing on functional mobility. The physical therapist monitors progress and makes adjustments to the therapy plan as needed.
Detailed session notes including date, time, patient identification, specific goals addressed, interventions used, patient response, and any modifications to the protocol. Documentation should reflect the technician’s qualifications, the supervising professional's involvement, and adherence to the established protocol.Progress notes should align with the treatment plan and support medical necessity.
** Thorough documentation is critical for successful claims processing.Clarify any variations from the established protocol in the session notes.Consult payer-specific guidelines for billing and coding requirements.
- RVU: Information not available in provided text.RVUs vary by payer and location.
- Global Days: Not applicable to this code.
- Payment Status: Active
- Modifier TC rule: Not applicable.This code represents the entire service.
- Fee Schedule: Information not provided.Fee schedules vary by payer and location.
- Specialties:Behavioral health, neurology, occupational therapy, physical therapy, speech therapy, developmental pediatrics, psychology.
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, School, Home, Other Place of Service (depending on treatment setting).