Association of Professional Behavior Analysts Logo

Update from the ABA Coding Coalition 

Date postedDecember 15, 2025
APBA Reporter,

Update from the ABA Coding Coalition 

Jenna W. Minton, Esq. 

2025 has proven to be a very busy year for the ABA Coding Coalition!  We have been working on several initiatives that we hope will benefit providers and the broader ABA health care services community. Here is a summary of our activities across several categories:

Payer education and outreach 
  • The Coalition has observed the following trends among payers in 2025, and has written letters to payers to educate them on correct implementation of the 2019 CPT® codes for adaptive behavior/ABA services and urge them to modify their policies accordingly: 

      • Lack of adherence to the American Medical Association (AMA) CPT® rounding rules for time-based CPT codes 

    • A proposal to discontinue coverage of code 97155 by New Hampshire Medicaid 

    • Incorrect implementation of codes 97155 and 97158 related to “protocol modification” activities  

    • Misunderstandings about the group treatment codes 97154 and 97158 – when to use them and how they differ from one another  

 

Advocacy efforts 

  • Telehealth coverage of ABA codes – COVID-19 temporary coverage ending  

    • The Coalition, in collaboration with the Council of Autism Service Providers (CASP) federal lobbying team, has actively encouraged legislators and the Centers for Medicare & Medicaid Services (CMS) to extend temporary coverage of telehealth delivery of the adaptive behavior/ABA CPT codes through the September 2025 expiration date.   

    • CMS finalized approval of  the adaptive behavior/ABA CPT codes for telehealth on a permanent basis as part of its efforts to streamline and simplify the telehealth coverage determination process for 2026. This change takes effect on January 1, 2026. It is important to note that this policy relates specifically to Medicare and Medicaid programs, and while commercial health plans may choose to mirror this policy, they are not required to do so. Providers should consult individual payer policies in the new year to see what their telehealth coverage entails.  

  • U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reports on Medicaid payments for ABA services 

    • Following release of HHS OIG reports on Indiana Medicaid in December 2024 and Wisconsin Medicaid in July 2025, the Coalition joined with several other organizations to engage the OIG in discussions about their findings on improper and potentially improper payments for ABA services in those states.  

    • During a meeting with the OIG in September 2025, representatives of the Coalition and other groups addressed some misunderstandings that were evident in the Indiana and Wisconsin OIG reports and learned about the OIG’s plans for conducting a broader review.  The OIG has agreed to join the Coalition and others during presentations at the upcoming APBA and CASP conferences to share their findings and answer questions. 

 

  • Comments on the 2026 Medicare Physician Fee Schedule Proposed Rule 

    • As we have done annually, the Coalition provided written comments to CMS on their Notice of Proposed Rulemaking (NPRM) for 2026.  We urged CMS to keep the adaptive behavior/ABA services CPT codes carrier-priced  (meaning that providers would continue negotiating rates with payers) and to finalize their proposal to approve the adaptive behavior/ABA services codes for telehealth coverage on a permanent basis. 

 

  • Other goals and initiatives 

    • Elevating the Category III (temporary) CPT codes to Category I (permanent) status and other improvements to the adaptive behavior services code set 

  • Although the specific changes to the adaptive behavior/ABA services code set remain confidential until they are released by the AMA, we can share that the Panel accepted the following changes to our code set: 

        • the addition of six new Category I CPT codes 

  • the revision of codes 97151-97158 

    • the revision of guidelines around usage of the code set,  

    • deletion of the existing T codes 

  • Detailed information will be distributed to providers and payers at the earliest possible opportunity. In the meantime, all parties must adhere to all AMA CPT confidentiality rules. Changes to the code set will take effect on January 1, 2027 and will be included in the 2027 CPT® Professional Code Book, which will be published in late 2026. 

 

  • Updating the Coding Coalition’s Model Coverage Policy (MCP) and information on our website, www.abacodes.org  

    • Updating website content on appropriate use of the adaptive behavior/ABA services CPT codes and related topics remains a key focus for the Coalition and will be a high priority in 2026. 

  • Advocating for improvements in Medically Unlikely Edits (MUEs) and National Correct Coding Initiatives (NCCI) edits that impact ABA providers  

    • The Coalition continues to advocate for improvements in the MUEs (per patient per day maximum units that may be reported for a given service) for the adaptive behavior/ABA services CPT code set, particularly to increase MUEs for code 97151 from the current Medicare MUE of 8 units per day. 

    • We also continue to advocate for changes to NCCI edits (procedure to procedure edits that direct whether services may be reported on the same day but not concurrently) for services such as speech, OT, and psychotherapy when delivered on the same day as ABA but not at overlapping times.  

 

Upcoming presentations  

  • APBA Annual Convention, March 2026 in New Orleans 

    • Workshop: Heads Up! The OIG Is Paying Attention—Are You Ready?

  • Invited Presentation: Hot Topics in Payer Policy and Coding - ABA Coding Coalition Annual Update

  • CASP Annual Conference, April 2026 in Las Vegas 

    • Coding Coalition Update 

  • OIG Updates 

 

Categories

Most Recent Posts