Autism Spectrum Disorder Services Daily Limits and Service Unit Contact Time

PROVIDER ALERT

Effective Jan. 1, 2020, the South Carolina Department of Health and Human Services (SCDHHS) will update daily limits for procedure codes for four Autism Spectrum Disorder (ASD) services and adopt the Medicare Eight Minute Rule to define service unit contact time for ASD services. The adoption of the Medicare Eight Minute Rule will be added to the ASD Services Provider Manual and the updated daily limits will be added to Section 4 of the manual by Jan. 1, 2020.

Effective for dates of service including and after Jan. 1, 2020, daily limits for the procedure codes listed below are as follows:

  • 97151 – 8 units
  • 97153 – 32 units
  • 97155 – 24 units
  • 97156 – 16 units

Providers should note that the weekly, monthly and annual limits previously listed in Section 4 are unchanged.

By adopting the Medicare Eight Minute Rule, SCDHHS is seeking to provide greater clarity to providers regarding how they can bill for services that are provided for less than eight minutes. Under this policy, a provider may not bill for a unit of service if the service is provided for less than eight minutes and it is the only ASD service provided to the beneficiary that day. If any ASD service is performed for seven minutes or less on the same day as another ASD service with the same procedure code that was also performed for seven minutes or less to the same beneficiary, then the provider may combine those encounters and bill for the appropriate number of units using the table below.

 

Units

Number of Minutes

1 unit

≥ 8 minutes through 22 minutes

2 units

≥ 23 minutes through 37 minutes

3 units

≥ 38 minutes through 52 minutes

4 units

≥ 53 minutes through 67 minutes

5 units

≥ 68 minutes through 82 minutes

6 units

≥ 83 minutes through 97 minutes

7 units

≥ 98 minutes through 112 minutes

8 units

≥ 113 minutes through 127 minutes

        The pattern remains the same for treatment times in excess of 2 hours. 

The expectation is that a provider’s direct beneficiary contact time for each unit will average at least 15 minutes in length. If a provider has a consistent practice of billing less than 15 minutes for a unit, these encounters will be highlighted for review.

Please refer any questions or concerns regarding this alert to the SCDHHS Division of Behavioral Health at (803) 898-2565.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

Tags: 
Report Fraud