How To Use CPT Code 97156

CPT 97156 refers to family adaptive behavior treatment guidance provided by a physician or qualified health care professional, and this article will cover its description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples.

1. What is CPT 97156?

CPT 97156 is a medical billing code used to describe family adaptive behavior treatment guidance services provided by a physician or other qualified health care professional. This code is used when the provider discusses a patient’s adaptive behavior treatment face-to-face with the guardian(s) or caregiver(s), with or without the patient present. The purpose of this treatment is to address the patient’s specific target problems and treatment goals, which are defined in previous assessments. The treatment is based on principles such as analysis and alteration of contextual events and motivating factors, stimulus consequence strategies and replacement behavior, and monitoring of outcome metrics.

2. 97156 CPT code description

The official description of CPT code 97156 is: “Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.”

3. Procedure

1. The provider meets with the patient’s guardian(s) or caregiver(s) face-to-face, with or without the patient present.
2. The provider discusses the patient’s problem behaviors or skill deficits with the guardian(s) or caregiver(s).
3. The provider explains the treatment protocol and teaches the guardian(s) or caregiver(s) how to interact with the patient to reduce maladaptive behaviors and/or skill deficits.
4. The provider monitors the patient’s progress and adjusts the treatment plan as needed.
5. The provider documents the duration and content of the session, as well as the patient’s progress and any changes to the treatment plan.

4. Qualifying circumstances

Patients eligible to receive CPT code 97156 services are those who have been diagnosed with behavioral or developmental disorders that require adaptive behavior treatment. This may include patients with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), or other conditions that result in maladaptive behaviors or skill deficits. The treatment must be deemed medically necessary by the patient’s primary care provider, and the provider administering the treatment must be a physician or other qualified health care professional.

5. When to use CPT code 97156

It is appropriate to bill the 97156 CPT code when the provider has conducted a face-to-face session with the patient’s guardian(s) or caregiver(s) to discuss the patient’s adaptive behavior treatment plan, with or without the patient present. This code should be used for each 15-minute increment that the provider spends face-to-face with the patient’s guardian(s) or caregiver(s).

6. Documentation requirements

To support a claim for CPT 97156, the following information must be documented:

• Patient’s diagnosis and medical necessity for adaptive behavior treatment
• Provider’s credentials as a physician or other qualified health care professional
• Date, start and end time, and duration of the session
• Content of the session, including discussion of problem behaviors or skill deficits, explanation of treatment protocol, and instruction for guardian(s) or caregiver(s)
• Patient’s progress and any changes to the treatment plan

7. Billing guidelines

When billing for CPT code 97156, it is important to follow these guidelines:

• Report the code for each 15-minute increment spent face-to-face with the patient’s guardian(s) or caregiver(s).
• Do not report 97156 in conjunction with codes 90785-90899, 96105-96171.
• Ensure that the provider’s credentials as a physician or other qualified health care professional are documented.
• Verify that the patient’s diagnosis and medical necessity for adaptive behavior treatment are documented.
• Maintain thorough documentation of the session, including date, start and end time, duration, content, and patient progress.

8. Historical information

CPT 97156 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 97156

Five similar codes to CPT 97156 and how they differentiate are:

1. CPT 97151: Focuses on the assessment of the patient’s adaptive behavior treatment needs, rather than guidance for the family.
2. CPT 97152: Involves direct one-on-one adaptive behavior treatment provided by a technician, rather than guidance for the family.
3. CPT 97153: Involves direct one-on-one adaptive behavior treatment provided by a physician or other qualified health care professional, rather than guidance for the family.
4. CPT 97154: Involves group adaptive behavior treatment provided by a technician, rather than guidance for the family.
5. CPT 97155: Involves group adaptive behavior treatment provided by a physician or other qualified health care professional, rather than guidance for the family.

10. Examples

1. A physician meets with the parents of a child with autism to discuss the child’s problem behaviors and provide guidance on how to implement an adaptive behavior treatment plan at home.
2. A qualified health care professional meets with the caregiver of an adult with ADHD to review the patient’s progress in adaptive behavior treatment and provide recommendations for continued improvement.
3. A physician meets with the guardian of a child with a developmental disorder to discuss the child’s skill deficits and provide instruction on how to support the child’s development through adaptive behavior treatment.
4. A qualified health care professional meets with the parents of a child with autism to review the child’s progress in adaptive behavior treatment and adjust the treatment plan as needed.
5. A physician meets with the caregiver of an adult with a behavioral disorder to discuss the patient’s maladaptive behaviors and provide guidance on how to implement an adaptive behavior treatment plan.
6. A qualified health care professional meets with the parents of a child with ADHD to discuss the child’s problem behaviors and provide recommendations for continued improvement through adaptive behavior treatment.
7. A physician meets with the guardian of a child with a developmental disorder to review the patient’s progress in adaptive behavior treatment and provide instruction on how to support the child’s development.
8. A qualified health care professional meets with the caregiver of an adult with a behavioral disorder to discuss the patient’s skill deficits and provide guidance on how to implement an adaptive behavior treatment plan.
9. A physician meets with the parents of a child with autism to review the child’s progress in adaptive behavior treatment and adjust the treatment plan as needed.
10. A qualified health care professional meets with the guardian of a child with a developmental disorder to discuss the child’s maladaptive behaviors and provide recommendations for continued improvement through adaptive behavior treatment.