How To Use CPT Code 97158

CPT 97158 describes the administration of group adaptive behavior treatment with protocol modification by a physician or other qualified healthcare professional. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 97158?

CPT 97158 can be used to describe the administration of group adaptive behavior treatment with protocol modification by a physician or other qualified healthcare professional. This code is used when the provider spends face-to-face time with multiple patients in a group setting, observing and adjusting therapeutic techniques to address social deficit targets and problem behaviors. The treatment aims to improve social relationships, reduce repetitive and aberrant behavior, and enhance communication and social functioning.

2. Official Description

The official description of CPT code 97158 is: ‘Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.’

3. Procedure

1. The provider conducts group adaptive behavior treatment in a social skills group.
2. The provider observes patients in the group setting and adjusts therapeutic techniques in real-time to address social deficit targets and problem behaviors.
3. Each participant is given specific measurable goals to contribute to the success of their social relationships.
4. The provider adjusts the level of assistance, such as prompts and feedback, based on each member’s skill level and ongoing progress.
5. The provider concludes the group session by summarizing the behavioral treatment principles, answering questions, and assigning individual homework to practice specific social skills.

4. Qualifying circumstances

CPT 97158 is applicable when a physician or other qualified healthcare professional administers group adaptive behavior treatment with protocol modification. The treatment targets specific social deficit goals and problem behaviors identified in previous assessments. It aims to improve communication, social functioning, and reduce repetitive and aberrant behavior. This code should not be reported if the group has more than eight patients or in conjunction with codes 90785-90899, 96105-96171, 92508, or 97150.

5. When to use CPT code 97158

CPT code 97158 should be used when a physician or other qualified healthcare professional spends face-to-face time with multiple patients in a group setting, providing adaptive behavior treatment with protocol modification. This code should be reported for each 15-minute increment of the session. It should not be reported if the group has more than eight patients or in conjunction with specific codes related to other services.

6. Documentation requirements

To support a claim for CPT 97158, the provider must document the following information:

• Specific social deficit targets and problem behaviors addressed in the treatment
• Individual measurable goals assigned to each participant
• Summary of the behavioral treatment principles discussed during the session
• Start and end time of the session
• Level of assistance provided to each member based on their skill level and progress
• Individual homework assignments given to each member

7. Billing guidelines

When billing for CPT 97158, ensure that the provider administering the treatment is a physician or other qualified healthcare professional. The session should be face-to-face with multiple patients in a group setting, with each 15-minute increment reported separately. Do not report CPT 97158 if the group has more than eight patients or in conjunction with specific codes related to other services.

8. Historical information

CPT 97158 was added to the Current Procedural Terminology system on January 1, 2019. There have been no updates to the code since its addition.

9. Examples

1. A physician conducting a group adaptive behavior treatment session with five patients, addressing their social deficit targets and problem behaviors.
2. A qualified healthcare professional administering adaptive behavior treatment in a group setting, adjusting therapeutic techniques to improve communication and social functioning for three patients.
3. A physician providing group adaptive behavior treatment with protocol modification, observing and adjusting therapeutic techniques for six patients to reduce repetitive and aberrant behavior.
4. A qualified healthcare professional conducting a group session, assigning individual measurable goals to four patients to enhance their social relationships.
5. A physician administering group adaptive behavior treatment, summarizing behavioral treatment principles and assigning individual homework to practice specific social skills for a group of seven patients.
6. A qualified healthcare professional conducting a group session, adjusting the level of assistance based on each member’s skill level and ongoing progress in addressing their social deficit targets and problem behaviors.
7. A physician providing group adaptive behavior treatment with protocol modification, observing patients in a group setting and addressing their specific social deficit goals and problem behaviors.
8. A qualified healthcare professional administering adaptive behavior treatment in a group session, assigning individual measurable goals to each participant to contribute to the success of their social relationships.
9. A physician conducting a group session, adjusting therapeutic techniques in real-time to address social deficit targets and problem behaviors for a group of five patients.
10. A qualified healthcare professional providing group adaptive behavior treatment, summarizing the behavioral treatment principles discussed during the session and answering questions from a group of six patients.