ABA Billing 101: A Beginner’s Guide to CPT Codes
If you work in applied behavior analysis (ABA), you've probably heard numbers like 97153, 97155, and 97156 thrown around. Maybe you know that 97153 is commonly used for direct care by a technician. Perhaps you've heard your supervisor say they're “billing 97155.” Or maybe you're a newly certified BCBA trying to make sense of authorizations, units, modifiers, and billing codes, and realizing, like many do, that you didn't learn about billing during your fieldwork hours.
You're not alone. Following our recent coverage of the 2027 ABA CPT® code changes, we heard from ABA professionals, particularly students, RBTs, and newly certified analysts, who wanted us to take a few steps back and explain the foundational concepts behind ABA billing.
And that's exactly what this guide is designed to do. Think of it as a starting point for understanding the language of CPT codes and ABA billing.
A quick note: This article is intended as a general educational introduction to CPT coding for ABA professionals. Billing requirements vary by payer, state, provider contract, and other factors. Always refer to the current CPT Codebook and the specific requirements of the payer you're working with.
How Did ABA Become an Insurance-Funded Service?
Before diving into CPT codes, it helps to understand why ABA providers use healthcare billing codes in the first place. ABA wasn't always funded through health insurance the way it is today.
Historically, access to funding for ABA was limited in many parts of the country. Some families paid for services out of pocket, which could be extremely costly. Others accessed ABA through state or local programs.
Health insurance coverage for ABA for the treatment of autism expanded significantly over time. Beginning in the late 2000s and continuing throughout the 2010s, states increasingly enacted laws requiring certain health plans to cover autism-related services.
In 2014, the Centers for Medicare & Medicaid Services (CMS) further shaped the trajectory of ABA coverage with a federal bulletin clarifying states' obligations to cover medically necessary services for Medicaid-enrolled children with autism under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
EPSDT requires states to provide Medicaid-enrolled individuals under age 21 with medically necessary services that fall within the categories of services covered under federal Medicaid law when needed to "correct or ameliorate a condition." With that, the 2014 CMS guidance didn't mandate ABA specifically. Rather, it clarified that states were required to make medically necessary covered services available to eligible children with autism. By 2022, all 50 states had adopted Medicaid coverage for ABA therapy, with Texas becoming the final state to implement an ABA benefit.
As private insurance coverage expanded and states addressed their Medicaid obligations, more families gained access to ABA through healthcare coverage. ABA providers, in turn, found themselves increasingly operating within the broader healthcare system.
And healthcare reimbursement requires a standardized way to communicate what service was actually provided to get paid for that service. That brings us to the obvious next question: What exactly is a CPT code?
What Is a CPT Code?
CPT® stands for Current Procedural Terminology. CPT codes are standardized, five-digit codes used to describe healthcare services and procedures. Essentially, CPT codes give healthcare providers and payers a common language for communicating what service was provided.
Who is a Payer?
A payer is the organization responsible for paying for healthcare services. In ABA, this commonly includes private health insurance companies and government programs like Medicaid.
It's important to note that this article focuses specifically on insurance- and Medicaid-funded ABA services. ABA professionals working in schools or other settings may operate outside of the healthcare reimbursement system and may not use CPT codes at all.
Why Do We Need a Common Language?
When billing for healthcare services, providers need a standardized way to communicate exactly what service was delivered so the payer can accurately process the claim.
A provider can't simply submit a claim that says, “We delivered ABA therapy for four hours.” That doesn't tell the payer enough.
Who provided the service? Was it a behavior technician or a qualified healthcare professional (QHP)? Was the service provided directly to the patient, or was the provider working with a caregiver? Was the provider conducting an assessment? Directing a technician? Providing treatment directly to the patient? Was the service provided individually or in a group? CPT codes give us a standardized way to communicate those differences. And those differences matter because different services may have different coverage requirements, provider qualifications, authorization limits, and reimbursement rates.
Who Creates CPT Codes?
The CPT code set is developed and maintained by the American Medical Association (AMA) through its CPT Editorial Panel. The code set is updated annually to reflect changes in healthcare services and medical practice, though that doesn't mean the codes used for ABA change every year. For ABA, major changes to the adaptive behavior CPT codes took effect in 2019, with another significant round of additions and revisions taking effect January 1, 2027.
Insurance companies don't create CPT codes. The AMA maintains the CPT code set and defines the services represented by those codes. Payers then establish their own policies regarding whether and under what circumstances those services are covered and reimbursed.
Where Does the ABA Coding Coalition Fit In?
While the AMA maintains the CPT code set, ABA professionals and organizations have played an important role in developing and advocating for codes that accurately describe adaptive behavior services. Much of that work is coordinated through the ABA Coding Coalition, a group of organizations representing behavior analysis, autism services, and related stakeholders. The Coalition works to develop and revise coding proposals for adaptive behavior services, advocate for appropriate coding and valuation of those services, and educate providers and payers about the codes.
How Do You Read an ABA CPT Code?
The code descriptor tells you specific information about the service a CPT code represents.
When reading an ABA CPT code, the descriptor can tell you things like:
What service is being provided (e.g., assessment; adaptive behavior treatment)
How it's being provided (e.g., by protocol; with analysis)
Who is providing it (e.g., a technician or QHP)
Who needs to be present (e.g., patient; caregiver)
How the service is reported (e.g., each 15 minutes)
CPT Code Example: 97153
Let's use 97153 as an example. In 2027, 97153 is described as adaptive behavior treatment by protocol, administered by a technician, face-to-face with one patient, each 15 minutes.
Here's what each part tells us:
Part of the Descriptor | What It Tells Us |
Adaptive behavior treatment | WHAT service is being provided |
By protocol | HOW the service is being provided—the provider is implementing an established treatment protocol |
Administered by technician | WHO is providing the service |
Face-to-face with one patient | WHO must be present and how the service is delivered |
Each 15 minutes | HOW TIME is reported for the service |
We'll break these terms down further in the section ahead.
Terminology
Let's break down some of the terms you'll encounter when reading ABA CPT codes.
Adaptive Behavior Treatment
You'll see the term adaptive behavior treatment throughout the ABA CPT code set. So, what does it mean?
Adaptive behavior services can address deficits in skills such as:
Instruction following
Verbal and nonverbal communication
Imitation
Play and leisure
Social interactions
Self-care
Daily living
Personal safety skills
Adaptive behavior services can also address harmful behaviors that risk physical harm to the patient, others, or property.
Technicians vs Qualified Healthcare Professionals (QHPs)
ABA CPT code descriptors specify the type of provider who performs the service. Depending on the code, this may be a technician or a qualified healthcare professional (QHP).
A technician provides services under the direction of a QHP. In ABA, this would typically be a behavior technician (BT) or Registered Behavior Technician (RBT).
A qualified healthcare professional (QHP) is a healthcare professional who, based on education, training, licensure or regulation, and scope of practice, is qualified to independently perform and report a professional service.
In ABA, a Board Certified Behavior Analyst (BCBA) or Licensed Behavior Analyst (LBA) may serve as the QHP.
What About BCaBAs?
A Board Certified Assistant Behavior Analyst (BCaBA) provides behavior-analytic services under the supervision of a BCBA and cannot practice independently. Because the AMA's definition of a qualified healthcare professional involves independently performing and reporting a professional service, BCaBAs don't meet the definition of a QHP.
However, this doesn't necessarily mean a BCaBA can never provide services reported under codes that specify a QHP. This is where it can get complex because payer-specific requirements and guidelines come into play. For example, several state Medicaid programs recognize BCaBAs or other mid-level providers and establish their own requirements for which services those providers can perform and report.
Remember: A CPT code tells you what service is being reported and who the CPT descriptor specifies performs it, but the payer determines which provider types it recognizes and under what circumstances it will cover and reimburse that service.
By Protocol Vs With Analysis
Another distinction you'll see in ABA CPT codes is whether a service is provided “by protocol” or “with analysis.”
Code 97153, for example, describes treatment by protocol. This means the provider is implementing an established treatment protocol. The technician follows the treatment procedures as written rather than independently analyzing the patient's response and making clinical decisions about how treatment should be modified.
“With analysis,” on the other hand, means the service includes clinical analysis and decision-making by the QHP. The QHP isn't simply implementing an existing protocol. They're analyzing the patient's behavior and response to treatment and using that information to make clinical decisions as part of the service.
Harmful Behavior
Some ABA CPT codes describe services to address harmful behavior.
Harmful behavior is described as behavior that jeopardizes the patient's health or safety or poses a risk of harm or medical consequences.
Harmful behavior can include:
SIB
Aggression
Property destruction
Pica
Elopement
Feeding difficulties
Sleep difficulties
Rumination
Bruxism
Mouthing objects
Inadequate fluid intake
Skin picking
Resistance to or lack of cooperation with medical or dental procedures
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Face-to-Face Versus Non-Face-to-Face
Another important distinction in ABA CPT codes is whether a service is delivered face-to-face or non-face-to-face.
For face-to-face services, the provider must be actively engaging with the person specified in the code descriptor, such as the patient or caregiver. However, face-to-face doesn't necessarily mean in-person. Some services may be delivered via telehealth while still meeting the face-to-face requirement. Whether a particular service can be delivered and billed via telehealth depends on payer policy and other applicable requirements.
Beginning in 2027, code 97180 will be available to report certain non-face-to-face clinical services performed by a QHP.
LEARN MORE: CPT Code 97180: What BCBAs Need to Know
What Does "Each 15 Minutes" Mean?
You'll notice that ABA CPT code descriptors end with “each 15 minutes.” This means the service is time-based and reported in 15-minute units.
15 minutes = 1 unit
30 minutes = 2 units
45 minutes = 3 units
60 minutes = 4 units
So, for example, three hours of a service equals 12 units of time. CPT time-reporting rules and payer-specific requirements determine how much time can actually be reported.
What Is Prior Authorization?
Now let's talk about another important component of insurance-funded ABA: authorization. Many payers require prior authorization, meaning certain services must be approved by the payer before they're provided. If you've ever heard a BCBA talk about "requesting authorization" for services, that's what they mean.
Authorization is typically requested after an initial assessment and the development of a treatment plan. The payer reviews the request and determines which services—and how much of those services—it will authorize.
In ABA, authorizations are commonly granted for six-month periods, though this varies by payer. Near the end of the authorization period, the QHP typically submits a reauthorization request for continued services.
An ABA authorization may specify:
Which CPT codes are authorized
How many units are approved for each code
The dates during which those units may be used
Other limitations or requirements
Keep in mind: Authorization isn't a guarantee of payment. After delivering the service, the provider submits a claim for reimbursement. Claims can still be denied if the service doesn't meet coding, documentation, eligibility, or other payer requirements.
What Are Modifiers?
You may also see a CPT code followed by two characters, such as HM or HN. These are called modifiers. They provide additional information about a service without changing the underlying CPT code. In ABA, payers may use modifiers to communicate additional information, such as the type or level of provider who delivered the service.
What About H-Codes?
CPT codes aren't the only codes you may encounter in ABA. Depending on your state and payer, you may see codes beginning with the letter H, such as H0032 or H2019. These are HCPCS Level II codes, not CPT codes.
HCPCS (Healthcare Common Procedure Coding System) is another coding system used for healthcare services, supplies, and other items. Because CPT codes are the most widely used codes in ABA, we won't go too far into detail on H-codes. But once again, a reminder that payer-specific requirements matter.
Putting It All Together
ABA billing can feel like another language when you're first introduced to it—and, in a way, it is. There are CPT codes, modifiers, units, authorizations, payer policies, and provider requirements, all working together within a system that isn't always intuitive.
With significant changes to the adaptive behavior CPT code set taking effect January 1, 2027, now is a particularly important time for ABA professionals to understand what these codes mean.
Continue Learning About the 2027 ABA CPT Codes
Looking for more detail on CPT codes, including the upcoming 2027 changes? Check out these resources.
Note: As of this article's publication, the FAQs haven't been updated to reflect 2027
changes.
Disclaimer: ABA Resource Center is not affiliated with ABA Coding Coalition. We're an independent, BCBA-owned organization focused on sharing resources and disseminating information to the ABA community. This article is for informational purposes only and should not be considered billing, coding, legal, or reimbursement advice. Providers should consult the official 2027 CPT® code set and applicable payer guidance when determining how to report services.
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