How To Use CPT Code 97155

CPT 97155 is a code for adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional. This article will cover the description, procedure, qualifying circumstances, billing guidelines, documentation requirements, historical information, similar codes, and examples of CPT 97155.

1. What is CPT 97155?

CPT 97155 is a medical billing code used for adaptive behavior treatment with protocol modification. This treatment is administered by a physician or other qualified healthcare professional and involves making modifications to the protocol targets and treatment techniques for a patient’s adaptive behavior. The code is reported for each 15 minutes of service provided.

2. 97155 CPT code description

The official description of CPT code 97155 is: “Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.”

3. Procedure

The procedure for CPT 97155 involves the following steps:

1. The provider, a physician or other qualified healthcare professional, assesses the patient’s adaptive behavior and identifies areas that require modification.
2. The provider modifies the protocol targets and treatment techniques based on the patient’s needs and goals.
3. The provider demonstrates the new or modified protocol to a technician, who will then implement the changes with the patient.
4. The provider monitors the patient’s progress and makes further modifications as needed.
5. The provider documents the services provided and the patient’s progress for billing purposes.

4. Qualifying circumstances

Patients eligible to receive CPT code 97155 services are those who require adaptive behavior treatment with protocol modification. This may include individuals with autism spectrum disorder, intellectual disabilities, or other conditions that affect their adaptive behavior. The treatment must be administered by a physician or other qualified healthcare professional, and the patient’s progress must be monitored and documented.

5. When to use CPT code 97155

It is appropriate to bill the 97155 CPT code when a physician or other qualified healthcare professional administers adaptive behavior treatment with protocol modification to a patient. This code should be used for each 15 minutes of service provided, and the provider must document the services and the patient’s progress to support the claim.

6. Documentation requirements

To support a claim for CPT 97155, the following information must be documented:

• Patient’s diagnosis and the need for adaptive behavior treatment with protocol modification
• Specific protocol targets and treatment techniques that were modified
• Duration of the service provided, in 15-minute increments
• Progress made by the patient during the treatment
• Any additional modifications made to the protocol during the treatment
• Identification of the provider administering the treatment

7. Billing guidelines

When billing for CPT code 97155, it is important to follow these guidelines:

• Report the code for each 15 minutes of service provided
• Ensure that the provider administering the treatment is a physician or other qualified healthcare professional
• Document the services provided and the patient’s progress to support the claim
• Do not report CPT 97155 in conjunction with codes 90785-90899, 92507, 96105-96171, or 97129

8. Historical information

CPT 97155 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Similar codes to CPT 97155

Five similar codes to CPT 97155 and how they differ are:

• CPT 97151: This code is for initial assessment of adaptive behavior, conducted by a physician or other qualified healthcare professional.
• CPT 97152: This code is for adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional.
• CPT 97153: This code is for adaptive behavior treatment with protocol administration, administered by a technician with face-to-face direction from a physician or other qualified healthcare professional.
• CPT 97154: This code is for group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional.
• CPT 97156: This code is for family adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional with the patient present.

10. Examples

Here are 10 detailed examples of CPT code 97155 procedures:

1. A physician modifies the protocol targets for a child with autism to improve communication skills and reduce repetitive behaviors.
2. A qualified healthcare professional adjusts the treatment techniques for a patient with an intellectual disability to enhance their daily living skills.
3. A provider demonstrates a modified protocol to a technician for a patient with a developmental disorder to improve their social functioning.
4. A physician adjusts the protocol targets for a teenager with autism to address new behavioral challenges related to a change in their living situation.
5. A qualified healthcare professional modifies the treatment techniques for a patient with a cognitive impairment to improve their ability to follow instructions.
6. A provider demonstrates a new protocol to a technician for a patient with a behavioral disorder to reduce aggressive behaviors.
7. A physician modifies the protocol targets for a child with a developmental delay to improve their ability to engage in play with peers.
8. A qualified healthcare professional adjusts the treatment techniques for a patient with a neurological disorder to enhance their ability to complete self-care tasks.
9. A provider demonstrates a modified protocol to a technician for a patient with a learning disability to improve their academic skills.
10. A physician adjusts the protocol targets for a teenager with a behavioral disorder to address new challenges related to transitioning to adulthood.