April 6, 2022

Agency for Health Care Administration
Bureau of Medicaid Policy
2727 Mahan Drive, Mail Stop #23
Tallahassee, FL 32308

Re: 59G-4.002, Provider Reimbursement Schedules and Billing Codes

The Florida Association for Behavior Analysis would like to thank the Agency for Health Care Administration for working with FABA and providers of behavior analysis to make this transition to CPT codes as smooth as possible and to make certain that effective and ethical behavior analysis services are available to all Florida Citizens.

In the weeks since the proposed Behavior Analysis Fee Schedule was released, FABA has received feedback from many providers who are genuinely concerned with continuing to serve individuals with serious behavioral needs in our state. Of the many issues raised, the two primary concerns were:

  1. The rate table does not provide a modifier for procedure code 97153 when the treatment protocol is implemented by a BCBA, BCaBA or FL-CBA. Thus, when ongoing implementation of the treatment plan requires the skills of a more qualified practitioner, they must bill at the RBT rate (a 36% rate cut for BCBAs). AHCA should recognize that although the RBTs provides a valuable service, their training is limited and may not be appropriate for individuals with all types of challenging behaviors. There are a number of other situations that may require treatment to be provided by a BCBA-D, BCBA, BCaBA or FL-CBA rather than an RBT. These may include those individuals who require more sophisticated treatment which goes beyond the training and scope of practice of the RBT, the limited number of hours needed for each code making it most appropriate for one practitioner to provide all services, situations when more intensive services are being faded as well as a variety of workforce issues that impact the availability of RBT’s. FABA understands that AHCA wants to encourage the Pyramidal model when this is appropriate, but as stated above this is simply not appropriate for all recipients. The prior authorization process can be used to limit the use of BCBA and BCaBA services when RBT level providers would be more appropriate. The proposed implementation date for the new codes is July 1, 2022. FABA recommends that a more gradual transition to the new codes is needed to allow providers who do not currently have RBT level staff to attempt to hire them. Alternatively, this would give families a chance to find providers who use the pyramidal model. FABA recommends that modifier codes be added to procedure 97153 so that appropriate rates can be billed when treatment is implemented by a BCBA, BCBA-D or BCaBA. Our providers have informed us if modifiers are not added to 97153, many children with serious challenging behavior will lose services from their current providers.
  2. The current rate table suggests that concurrent billing 97155 with 97153 and 97154 is not allowed. It was clearly the intent of the AMA that these are distinct services and concurrent billing should be allowed. Medicaid plans in many states, and many insurance providers do allow such concurrent billing. Many of these other providers also provide a significantly higher rate. Maintaining a robust provider network for Medicaid recipients will require somewhat competitive compensation rates and allowances. FABA recommends that the proposed fee schedule be modified to allow the Lead Analyst and RBT or BCaBA to bill at the same time, when clinical direction is being provided.

Other concerns raised include:

  • It may be desirable for AHCA to add a location modifier so that an analysis could be conducted of environments in which services were being provided.
  • Although FABA understands that the intent of the current rate proposal was not to increase rates, there is concern that the Medicaid rates are lower than neighboring states and other insurance providers in Florida.
  • Some providers will incur additional costs associated with use of the 97153 XP code. It might help if AHCA explains the purpose of the code and clearly defined its intended use since it is not in the proposed policy.

Eric Prutsman – [email protected]
Tiki Fiol - [email protected]
Mary Riordan - [email protected]