Portal Submission:
Relevant background: Can an ABA agency ask a BCBA/LBA to bill 97155 for conducting or training others to pass the RBT competency assessment, conduct performance checklists for service delivery or training new RBTs on company protocols (nap, diaper change, daily schedule, or data collections process) while the RBT bills 97153 time?
Possible solutions: I have asked the agency on further understanding on their specific request and how would that meet or violate ethical billing process.
Credentialing: Reporter is an LBA
Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):
Disclaimer: The following guidance is based on relevant experience and resources and may differ by payor. This guidance is not intended as legal advice.
Billing practices are determined by the payer contract and national coding guidelines, not by agency policy. Under no circumstances is it permissible for a BCBA/LBA to bill for services that are not behavior analytic in nature, not individualized to a client, or not consistent with payer requirements. Billing for activities that are unrelated to client treatment goals, or for periods of time when behavior analytic services are not being delivered directly to the client, raises significant ethical and compliance concerns.
It is the responsibility of the supervising Licensed Behavior Analyst to ensure compliance with all billing standards as outlined by the payer contract, the American Medical Association, the Centers for Medicare and Medicaid Services (CMS), and the National Correct Coding Initiative (NCCI). Regardless of agency requests, the individual provider remains accountable to state law and professional ethics requirements. Practitioners who are unable or unwilling to align with these standards are subject to Arizona Board of Psychologist Examiners (AZBoPE) and BACB disciplinary action.
Based on the portal submission, there may not be enough information to determine if billing would be permissible in these instances. As general guidance, funders require that in order to bill for a medical service, all outlined requirements must be met for each code, with the main focus of the session being on the client’s individualized treatment plan.
- 97155 requires that the QHP be actively engaged in clinical protocol modification for the client. Merely observing services, conducting general training, or completing tasks unrelated to treatment protocols does not meet the threshold for 97155 and should not be billed to a client’s funder. If, however, a new technician is being observed for accuracy on implementing a protocol and a QHP is observing client’s response to that implementation, this may be allowable for billing 97155.
- 97153 requires the RBT to deliver treatment directly to the client in accordance with written protocols developed by the BCBA. If a technician is not actively implementing treatment protocols with a client (for example, if the technician is present only for general training or competency tasks unrelated to the treatment plan and doing so while client is present), 97153 would not be billable.
The committee commends the reportee for raising this concern. We encourage practitioners to seek clarification from their agency, document their concerns, and, if necessary, take further steps to ensure compliance, including reporting to the licensure board or payer if ethical billing practices cannot be maintained. For additional resources, practitioners may consult the ABA Coding Coalition.
Considerations for exploration:
In accordance with the Ethics Code, the committee recommends:
- Documenting communication with supervisors or administrators regarding billing expectations.
- Educating colleagues and leadership on ethical and payer billing requirements when possible.
- Exploring formal reporting pathways (licensure board, payor Fraud/Waste/Abuse hotlines) if concerns are not resolved internally.
- Considering alignment of employment with organizations whose billing practices are consistent with ethical and legal requirements.
Ethics Codes (specific standards that could apply to support/oppose):
- 1.01 Being Truthful
- 1.02 Conforming with Legal and Professional Requirements
- 1.03 Accountability
- 2.06 Accuracy in Service Billing and Reporting
- 4.01 Compliance with Supervision Requirements
- 4.04 Accountability in Supervision
- A.R.S. § 32-2091 (12)(a)(e)(p)
Additional Resources:
