2025 CPT code 97158
(Active) Effective Date: N/A Revision Date: N/A Medicine Services and Procedures - Adaptive Behavior Services Medicine Feed
Group adaptive behavior treatment with protocol modification, administered by a physician or qualified healthcare professional, face-to-face with multiple patients (up to 8), per 15 minutes.
Modifiers may apply depending on the circumstances of service provision. Consult the most recent CPT guidelines for appropriate modifier use.
Medical necessity is established by a documented diagnosis of a behavioral or developmental disorder that warrants group adaptive behavior treatment.The treatment plan should demonstrate the need for real-time protocol modification to address patient-specific needs and ensure optimal outcomes.
The physician or qualified healthcare professional is responsible for assessing patient needs, designing and modifying the treatment protocol, and administering the treatment in a group setting.They directly interact with patients, providing real-time adjustments to the treatment plan based on individual responses and group dynamics.
In simple words: This code is for a doctor or therapist working with a small group (up to 8 people) to change behavior. The therapist watches the group, makes changes to the plan as needed, and works directly with each person during the session.
Group adaptive behavior treatment with protocol modification (97158) involves a physician or other qualified healthcare professional providing face-to-face services to multiple patients (maximum 8) in a group setting.The provider monitors individual patient needs and adjusts treatment techniques in real-time during the session. This differs from 97154, where adjustments are made for subsequent sessions.The code is reported for each 15-minute interval of face-to-face time.
Example 1: A psychiatrist conducts a group therapy session for 6 adolescents with Oppositional Defiant Disorder.They adjust techniques based on individual responses and group interactions, billing 97158 for each 15-minute interval of direct patient interaction., An occupational therapist works with a group of 4 autistic children on social skills.They modify activities in real-time based on each child's progress and responses, utilizing 97158 for each 15-minute interval., A behavioral therapist works with a group of 8 children with ADHD, modifying treatment strategies to address individual needs during a 45 minute session.They would bill for 3 units of 97158.
Detailed treatment plan outlining the goals, objectives, and specific techniques used. Progress notes documenting the patient's response to treatment, including any modifications made to the protocol.Documentation of the time spent in face-to-face interaction with the patients in a group setting.
** This code is specifically for group treatment with real-time protocol adjustments. If the therapist is only providing direction to a technician without direct patient interaction, a different code would apply.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Psychiatry, Psychology, Occupational Therapy, Behavioral Therapy
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital,Other Place of Service (depending on the setting)