INDIANA HEALTH COVERAGE PROGRAMS

1 INDIANA HEALTH COVERAGE PROGRAMS . P R O V I D E R C O D E T AB L E S. Mental HEALTH and Addiction Services Codes Note: Due to possible changes in INDIANA HEALTH COVERAGE PROGRAMS (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current COVERAGE . See IHCP Banner Pages and Bulletins and the IHCP. Fee Schedule for updates to coding, COVERAGE , and benefit information. Previous versions of code tables are archived for purposes of historical reference. For information about using these code tables, see the Mental HEALTH and Addiction Services provider reference module. Table 1 Procedure Codes for Applied Behavioral Analysis Therapy Table 2 ICD-10 Diagnosis Codes for Bridge Appointments Note: See Revenue Codes Linked to Specific Procedure Codes accessible from the Code Sets page at for procedure codes linked to revenue code 513 Clinic/Psychiatric for dates of service before March 15, 2018.

2 Table 1 Procedure Codes for Applied Behavioral Analysis Therapy Reviewed/Updated: January 1, 2019. Note: For ABA therapy prior authorizations (PAs) issued before January 1, 2019, see the procedure codes listed in the subsection at the end of this table. Procedure Code Description 97151 Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or other qualified healthcare professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/. interpreting the assessment, and preparing the report/treatment plan 97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, each 15 minutes 97153 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, every 15.

3 Minutes 97154 Group adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, with two or more patients, every 15 minutes Published: January 10, 2019 1. INDIANA HEALTH COVERAGE PROGRAMS Mental HEALTH and Addiction Services Codes Table 1 Procedure Codes for Applied Behavioral Analysis Therapy Reviewed/Updated: January 1, 2019. Procedure Code Description 97155 Adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, which may include simultaneous direction of a technician, face-to-face with one patient, every 15 minutes 97156 Family adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/.

4 Caregiver(s), every 15 minutes 97157 Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, every 15 minutes 97158 Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, face-to-face with multiple patients, every 15 minutes 0362T Behavior identification supporting assessment, each 15 minutes of technicians' time face-to- face with a patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized to the patient's behavior 0373T Adaptive behavior treatment with protocol modification, each 15 minutes of technicians'.

5 Time face-to-face with a patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized to the patient's behavior For Prior Authorizations Issued Before January 1, 2019. For PAs issued before January 1, 2019, the IHCP will continue to cover the following ABA therapy procedure code/ modifier combinations billed for dates of service through June 30, 2019. Procedure Code Description 96150 U1 HEALTH and behavior assessment (eg, HEALTH -focused clinical interview, behavioral observations, psychophysiological monitoring, HEALTH -oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment; ABA therapy assessment provided by BCBA, BCBA-D, or HSPP.

6 96150 U2 HEALTH and behavior assessment (eg, HEALTH -focused clinical interview, behavioral observations, psychophysiological monitoring, HEALTH -oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment; ABA therapy assessment provided by BCaBA. 96151 U1 HEALTH and behavior assessment (eg, HEALTH -focused clinical interview, behavioral observations, psychophysiological monitoring, HEALTH -oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment; ABA therapy re-assessment provided by BCBA, BCBA-D, or HSPP. 96151 U2 HEALTH and behavior assessment (eg, HEALTH -focused clinical interview, behavioral observations, psychophysiological monitoring, HEALTH -oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment; ABA therapy re-assessment provided by BCaBA.

7 96152 U1 HEALTH and behavior intervention, each 15 minutes, face-to-face; individual; ABA therapy provided by BCBA, BCBA-D, or HSPP. Published: January 10, 2019 2. INDIANA HEALTH COVERAGE PROGRAMS Mental HEALTH and Addiction Services Codes Table 1 Procedure Codes for Applied Behavioral Analysis Therapy Reviewed/Updated: January 1, 2019. *For Prior Authorizations Issued Before January 1, 2019. For PAs issued before January 1, 2019, the IHCP will continue to cover the following ABA procedure code/modifier combinations billed for dates of service through June 30, 2019. Procedure Code Description 96152 U2 HEALTH and behavior intervention, each 15 minutes, face-to-face; individual; ABA therapy provided by BCaBA.

8 96152 U3 HEALTH and behavior intervention, each 15 minutes, face-to-face; individual; ABA therapy provided by RBT. 96153 U1 HEALTH and behavior intervention, each 15 minutes, face-to-face; group; ABA therapy provided by BCBA, BCBA-D, or HSPP. 96153 U2 HEALTH and behavior intervention, each 15 minutes, face-to-face; group; ABA therapy provided by BCaBA. 96153 U3 HEALTH and behavior intervention, each 15 minutes, face-to-face; group; ABA therapy provided by RBT. 96154 U1 HEALTH and behavior intervention, each 15 minutes, face-to-face; family with patient present;. ABA therapy provided by BCBA, BCBA-D, or HSPP. 96154 U2 HEALTH and behavior intervention, each 15 minutes, face-to-face; family with patient present.

9 ABA therapy provided by BCaBA. 96154 U3 HEALTH and behavior intervention, each 15 minutes, face-to-face; family with patient present;. ABA therapy provided by RBT. 96155 U1 HEALTH and behavior intervention, each 15 minutes, face-to-face; family without patient present; ABA therapy provided by BCBA, BCBA-D, or HSPP. 96155 U2 HEALTH and behavior intervention, each 15 minutes, face-to-face; family without patient present; ABA therapy provided by BCaBA. 96155 U3 HEALTH and behavior intervention, each 15 minutes, face-to-face; family without patient present; ABA therapy provided by RBT. Table Revision History January 1, 2019, update: Added (effective January 1, 2019): 97151 97158, 0362T, 0373T.

10 All codes previously on this table moved to the For Prior Authorizations Issued Before January 1, 2019. subsection Published: January 10, 2019 3. INDIANA HEALTH COVERAGE PROGRAMS Mental HEALTH and Addiction Services Codes Table 2 ICD-10 Diagnosis Codes for Bridge Appointments Reviewed/Updated: May 1, 2017. Diagnosis Code Description Schizophrenia disorders Schizoaffective disorders F30-F39 Mood [affective] disorders F22 Delusional disorders F23, F28, F29 Other non-mood psychotic disorders Pervasive development disorders F42 Obsessive-compulsive disorder Dysthymic disorder Reaction to severe stress, and adjustment disorders Depressive disorder NOS. Conduct disorders , , Behavioral and emotional disorders with onset usually occurring in childhood and , adolescence Hyperkinetic syndrome of childhood Published: January 10, 2019 4.