Individual vs. Group ABA Therapy Billing: What You Really Need to Know

Running an ABA practice requires understanding the distinction between charging for one-on-one sessions and group therapy. It enables your team to submit claims correctly, adhere to regulations, and receive payment promptly. This easy step ensures that your work proceeds smoothly and that your billing procedure remains consistent. Each sort of billing is explained in this easy-to-follow guide, along with helpful management advice.

Get the Codes Correct: Individual and Group Session Billing

The first step to properly bill is selecting the appropriate ABA billing code for the session. The insurance company can learn what type of therapy was provided by using these codes, often known as CPT codes. Every session type has a unique code. Using the appropriate code:

• Helps ensure that claims are processed smoothly.

• Reduces the likelihood of payment rejection

• Maintains compliance with regulations in your profession

Incorrect code usage can result in:

• Postponed payments

• Your practice's financial loss

• Insurance or audit issues

Thus, matching the appropriate code to the appropriate ABA service is a simple yet significant step.

Individual Therapy Sessions

Individual sessions have distinct CPT codes based on the specifics of the therapy delivered:

97153 – This code covers adaptive behavior treatments provided directly to one individual by a technician under the supervision of a Qualified Health Professional (QHP). This service is billed in fifteen-minute intervals. For instance, the claim might show three units of 97153 if a technician spent forty-five minutes with a patient one-on-one.

97155 – When a Qualified Health Professional adjusts a patient's adaptive behavior treatment plan during individual therapy sessions, a specific CPT code is utilized to accurately reflect these modifications.

Group Therapy Sessions

Group therapy sessions differ significantly from individual sessions in terms of structure, provider roles, and billing codes:

97154 – applicable when a technician working under the supervision of a QHP administers adaptive behavior treatments in a group environment. Individual charges are made to each group session participant in 15-minute intervals. For instance, each client's invoicing will show four units of 97154 if four clients attend a technician-led group session lasting an hour.

97158 – This code is specifically for group adaptive behavior treatment sessions managed directly by a QHP, where treatment protocols are actively modified during the session. Billing is per 15-minute increment. If a qualified provider runs a 60-minute group session and adjusts the treatment during that time, you would bill four units of code 97158 for each child in the group.

What You Need to Watch Closely

Make sure your ABA billing clearly matches what actually happened in the session. Always show whether the session was one-on-one or done in a group.

Check the insurance company’s rules. Some may have limits on how many kids can be in a group, how long the session should last, or what notes must be written.

Understanding how CPT codes work within ABA billing services helps ensure accurate claim submission and keeps your practice in compliance.

Teach your billing and therapy staff often. It helps avoid mistakes, audits, and payment issues.

What Should ABA Providers Know About Supervision and Billing Nuances?

One of the most crucial aspects of billing for ABA therapy is taking thorough notes on the activities that took place during supervision. Follow BACB’s supervision standards to stay compliant and avoid billing risks. Safeguards your clinic in the event that your records are reviewed, expedites the processing of your claims, and facilitates timely payment.

One easy measure that keeps your practice safe and your billing solid is to take the time to note everything accurately.

Concurrent Billing

As long as the insurance company permits it, a supervisor may bill concurrently with a technician while the technician is doing services. In a group session, for instance, a technician may bill using code 97154 while a supervisor bills using code 97155. But this doesn't always work; it only does so in specific situations.

Every insurance provider has their own policies. While some permit this kind of billing, others do not. In an audit, your claims may be rejected or questioned if you don't follow their guidelines. Because of this, it's critical to carefully review the payer's guidelines and ensure that the amounts you bill align with their permitted amounts. Billing more than they authorize can lead to issues and payment delays.

Modifiers

Correct usage of modifiers clearly indicates provider qualifications and is critical for precise billing:

• HN: Indicates a provider with a Bachelor's degree (such as a BCaBA).

• HM: It refers to a provider (usually a behavior technician) who holds less than a bachelor's degree.

• HO: Denotes a provider holding a Master's degree (BCBA).

• HP: Represents a provider with a Doctoral degree (BCBA-D).

Documentation of Supervision

Comprehensive documentation detailing supervisory activities is vital. Records should include the supervisor’s oversight level, the specific interventions discussed, and direct interactions during therapy sessions. Detailed documentation supports accurate claims submission and meets compliance expectations.

The BACB Rules You Must Follow

Anyone doing supervision must have a current BCBA license and complete the necessary supervision training, according to the Behavior Analyst Certification Board (BACB). Your practice keeps out of trouble with the law and billing errors are less likely to occur when your supervisors follow these guidelines.

When services occur simultaneously, it's also critical to comprehend how billing operates and to adhere to the guidelines for note-taking. Maintaining accurate records and safeguarding your revenue are two benefits of doing this.

Why ABA Billing Needs Clear Notes

Clear and comprehensive notes must be written by your team in order to maintain compliance and keep your billing on schedule. You can avoid issues during audits by having strong documentation.

Individual Session Documentation

Detailed documentation for individual therapy sessions should include clearly outlined session goals, specific therapeutic interventions, patient responses, and measurable progress. Additionally, document the session's duration, techniques implemented, and any modifications to treatment protocols.

Group Session Documentation

Group session documentation requires capturing individualized progress notes, session objectives, group-specific adjustments, and precise details of the session duration and group size. Clearly indicating each participant's progress and specific therapeutic responses within the group setting enhances claim accuracy.

Compliance Tips

Make sure your notes are precise and explain the need for each therapy session. As required by each insurance provider, be careful to review and update these notes frequently. This reduces the likelihood of claims being denied.

About 20% more claims are allowed by ABA clinics with neat, well-organized records than by those with disorganized or missing notes. Not only does proper documentation help you get paid, but it also safeguards your practice in the event that your files are examined. Keep your practice safe from issues and your money flowing with proper documentation.

Picking the Proper NPI for Invoicing

For quicker payments, using the correct NPI is crucial, whether it is for the entire group or just one provider. Knowing who provided the care is beneficial to the insurance provider. Selecting the appropriate one helps you maintain orderly billing and a short payment period. Using the appropriate NPI is crucial to the goal of payment in 25 to 30 days, which is what most well-run ABA offices strive for.

Individual NPI (Type 1)

Individual NPIs are assigned directly to ABA therapists and direct-care providers, such as Board Certified Behavior Analysts (BCBAs) and Registered Behavior Technicians (RBTs). This identifier clearly indicates the specific provider rendering the therapy services.

Group NPI (Type 2)

Group NPIs are designated for incorporated ABA billing companies or group practices handling billing collectively. This type of NPI enables streamlined billing processes when multiple providers render services under one organization.

Billing Implications

When billing using a Group NPI, it is essential to include the Individual NPI of the rendering provider on each claim. Omitting the individual provider’s NPI can result in claim rejections, significantly delaying payment and increasing AR days.

Critical Insight

Sending claims and receiving payment on time is made easier when the correct NPI is used, whether it is for a single therapist or the entire group. Your ABA clinic may prevent confusion, save time, and ensure timely payments by knowing when to utilize a group or individual NPI. It's a little but crucial component in maintaining simplified and unambiguous billing.

How to Manage Insurance Regulations in ABA Invoicing

Every insurance provider operates differently. Other others demand different codes, and some require further documents. It's critical to understand how each one operates to prevent delays or rejected claims. Knowing these distinctions increases the likelihood that your claims will be processed successfully and that your payments will be made on schedule. This translates into a stable cash flow for your clinic and reduced stress for your staff.

Understanding Payer Variability

Payers have significantly different policies, making it critical for providers to become familiar with specific payer guidelines. This understanding prevents unnecessary denials and ensures smoother billing processes.

Negotiating Rates

When presenting detailed records of how their services benefit clients, therapists can strengthen their argument during rate negotiations. Asking for higher insurance reimbursement is made easier by providing evidence that the therapy is effective and has positive outcomes. This keeps the clinic's finances stable and increases revenue.

Avoiding Denials

ABA clinics should maintain accurate records, employ the correct ABA billing codes, and conduct frequent internal checks to verify their work. Starting these procedures early reduces the amount of additional work for the staff, expedites payments, and helps prevent claim denials.

Essential Update

Effective May 1, 2025, TRICARE's reimbursement policies will significantly vary based on provider credentials and service locations. Providers must carefully review these updates to ensure compliance and optimal reimbursement outcomes.

Comparison Table: Individual vs. Group Billing

Aspect	Individual Session Billing	Group Session Billing
CPT Codes	97153, 97155	97154, 97158
Documentation Complexity	High	Higher
Supervision Needs	Direct and Individualized	Direct but Group-focused
Reimbursement Rates	Generally Higher	Lower, varies by payer
AR Days Target	25 days	Up to 30 days

FAQ

1.What is the CPT code for group ABA therapy?

Use CPT code 97154 for group ABA therapy sessions, ensuring accurate billing and reimbursement for services provided by technicians supervised by qualified professionals.

2. How to choose between an Individual NPI and a Group NPI?

Choose an Individual NPI for billing under a specific therapist’s credentials; a Group NPI is for collective billing—include individual NPIs to avoid denials.

3. What are the essential documentation requirements for compliant group sessions? 

Compliant documentation for group sessions includes individual progress data, clearly stated session goals, treatment modifications, and detailed information about group sizes and interactions.

Conclusion

Knowing how to use CPT codes, selecting the appropriate NPI, and adhering to each insurance company's regulations are all necessary for properly handling ABA therapy billing. For ABA billing teams to get paid more and prevent claim denials, they must plan ahead, maintain accurate data, and adhere to the billing rules. These actions maintain the practice's financial stability and strength.

Ready to optimize your ABA billing process? Connect with a HIPAA-verified ABA billing service to streamline your billing operations, reduce AR Days, and boost your financial health today!