By Matt Harrington, BCBA · Behaviorist Book Club · Research-backed answers for behavior analysts
CPT code 97153 covers adaptive behavior treatment by protocol, which involves a behavior technician delivering one-on-one treatment to a client by implementing established behavioral protocols developed by the supervising BCBA. The key characteristic of 97153 is that the technician is following existing plans rather than making clinical modifications. CPT code 97155 covers adaptive behavior treatment with protocol modification, which involves the BCBA or BCaBA directly working with the client while simultaneously analyzing data and modifying treatment protocols based on clinical judgment. The critical distinction is that 97155 requires active clinical decision-making and protocol adjustment, not merely BCBA presence. Billing 97155 when the BCBA is observing or supervising without modifying protocols is inaccurate and may constitute upcoding.
BCBAs who are pressured to bill for services not rendered face a situation that implicates multiple ethical standards and potentially criminal law. The first step is to document the pressure in writing, including the date, the person applying the pressure, and the specific request. The second step is to refuse to participate in the billing inaccuracy, citing Code 2.14 which requires accurate billing practices. The third step is to report the concern through appropriate organizational channels. If internal channels are not responsive or if the pressure continues, the BCBA should consult with the BACB Ethics Department and consider reporting to relevant regulatory authorities. Filing false claims with insurance companies, particularly government-funded programs, carries severe penalties under the False Claims Act. BCBAs should never prioritize job security over ethical and legal compliance.
Documentation supporting ABA billing should include several elements for each billed service unit. Session notes should describe the specific activities performed, the behavioral targets addressed, the procedures used, the client's response to intervention, and any modifications made during the session. The documentation should reflect the type of service being billed, so a session billed as 97155 should describe protocol modifications that occurred, while a session billed as 97153 should describe protocol implementation. Time records should accurately reflect start and stop times for billed services. Progress reports should summarize data trends, clinical reasoning for treatment decisions, and justification for continued services. Treatment plans should be current and should describe the services authorized by the payer. All documentation should be completed contemporaneously or as close to the service delivery as possible.
Upcoding is the practice of billing for a more complex or higher-level service than was actually provided, resulting in higher reimbursement. In ABA, common upcoding scenarios include billing 97155 when the BCBA was present but not actively modifying protocols, which should be supervised 97153 time, billing individual session rates for services delivered in a group format, and billing BCBA-level codes for activities performed by behavior technicians. Upcoding is a significant concern because it inflates the cost of ABA services, may exhaust client insurance benefits prematurely, exposes organizations to fraud investigations and recoupment demands, and undermines the profession's credibility with insurance payers. Even when upcoding results from confusion rather than intent, it creates the same financial and legal consequences.
BACB restricted activities are those that require the clinical judgment and expertise of a BCBA or BCaBA, such as conducting functional analyses, designing treatment plans, interpreting data, and making clinical decisions. These activities generally align with CPT codes that specify BCBA-level involvement, including 97151 for assessment, 97155 for protocol modification, and 97156 for family guidance. Unrestricted activities are those that can be performed by behavior technicians under BCBA supervision, such as implementing established treatment protocols and collecting data. These activities generally align with CPT code 97153 for treatment by protocol. The alignment is not perfect, and some activities may fall in gray areas that require clinical judgment about the appropriate code. BCBAs should understand both systems and ensure that billing reflects the actual level of clinical involvement in each activity.
BCBAs should ask several key questions to evaluate organizational billing practices. Who makes billing code selections and what training have they received? Is there a written policy describing how clinical activities map to CPT codes? How is documentation reviewed before bills are submitted, and who is responsible for quality assurance? Are billed units reconciled with actual session times and activities? How does the organization handle situations where authorized services do not match clinical needs? What happens when billing errors are identified? Is there a process for staff to raise billing concerns without retaliation? How does the organization handle insurance audits? If the answers to these questions reveal gaps in billing oversight, unclear policies, or resistance to transparency, these are warning signs that merit further investigation and potentially corrective action.
BCBAs can face personal liability for billing irregularities in several ways. If a BCBA signs off on documentation or billing records that are inaccurate, they may be held personally responsible regardless of organizational policy. The BACB can take disciplinary action against individual certificants for billing violations under Code 2.14, including public censure, suspension, or revocation of certification. State licensing boards may impose separate disciplinary actions. In cases involving fraud against government-funded insurance programs, individual practitioners can face civil penalties under the False Claims Act and potentially criminal charges. The defense that the organization required or encouraged the billing practice does not relieve individual liability. BCBAs should understand that their signature on clinical documentation carries personal responsibility and should never sign documents that do not accurately reflect the services they or their supervisees provided.
Telehealth ABA billing requires careful attention to the specific requirements of the payer, the state regulatory environment, and the CPT code definitions. Some insurance companies require telehealth modifiers to be appended to standard CPT codes, while others have specific telehealth codes. BCBAs should verify that telehealth services are authorized under the client's benefit plan and that any required telehealth modifiers are correctly applied. The clinical activities performed during telehealth sessions should match the billed code just as they would for in-person services. Time-based billing should reflect actual service delivery time, not the scheduled session duration. Documentation should note the telehealth modality and should describe the clinical activities with the same specificity required for in-person services. BCBAs should be aware that some payers reimburse telehealth services at different rates and that state regulations regarding telehealth may impose additional requirements.
Supervision and direct treatment are distinct activities that correspond to different CPT codes and different clinical functions. Supervision involves the BCBA overseeing the work of behavior technicians, reviewing data, providing feedback on implementation, and ensuring treatment fidelity. Some supervision activities are not independently billable and are considered part of the overhead cost of providing ABA services. Direct treatment, billed under codes like 97155, involves the BCBA working directly with the client to assess behavior, modify treatment protocols, or provide clinical intervention. The critical distinction is that direct treatment codes require the BCBA to be engaged in clinical activities with the client, not merely observing or supervising a technician's work. Billing direct treatment codes for time spent supervising technicians, even when the supervision occurs in the client's presence, is a common form of billing inaccuracy that BCBAs should be vigilant about avoiding.
BCBAs can advocate for ethical billing through several strategies. First, develop your own billing literacy so that you can speak knowledgeably about CPT codes, documentation standards, and compliance requirements. Second, frame billing compliance as a business asset rather than merely an ethical obligation, emphasizing that accurate billing protects the organization from audits, recoupment, and legal liability. Third, propose specific improvements such as billing training for clinical staff, documentation review processes, and regular internal audits. Fourth, build alliances with colleagues who share your concerns, as collective advocacy is often more effective than individual efforts. Fifth, document your advocacy efforts in case you need to demonstrate that you raised concerns through appropriate channels. If organizational leadership is unresponsive to billing compliance concerns, BCBAs should consult with the BACB and consider whether the environment is compatible with their professional obligations under the Ethics Code.
The ABA Clubhouse has 60+ on-demand CEUs including ethics, supervision, and clinical topics like this one. Plus a new live CEU every Wednesday.
Ready to go deeper? This course covers this topic with structured learning objectives and CEU credit.
Ethical ABA Billing: CPT Codes in Plain English — Tina Guidry · 1 BACB Ethics CEUs · $20
Take This Course →1 BACB Ethics CEUs · $20 · BehaviorLive
Research-backed educational guide with practice recommendations
Side-by-side comparison with clinical decision framework
All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.