You have accessThe ASHA Leader ArchiveBottom Line1 May 2019

The Right Codes for ASD-Related Services

Make sure your diagnostic and billing code choices are complete and accurate when you bill for services to clients with ASD.

    Medicaid and private health insurance plans have significant latitude to determine specific coverage of services for autism spectrum disorder (ASD; see “What to Know About Mandated Coverage for Autism Services,” April 2019), even though most states mandate insurers to cover ASD-related treatment.

    And, just as coverage policies vary, so do diagnosis and procedure coding guidelines. Although there are clear coding and billing best practices, knowing and meeting the payers’ variations will help clinicians avoid claim denials. Clinicians should check directly with each payer for final guidance on billing and coding requirements.

    Clinicians use ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) diagnosis codes and CPT (Current Procedural Terminology ® American Medical Association) procedure codes to submit claims for ASD-related services. They may also use Health Care Common Procedure Coding System (HCPCS) Level II codes for equipment, such as augmentative and alternative communication devices.

    The information here is based on generally accepted coding principles. Consult the payer for clarification of coding or coverage on a specific case.

    What diagnosis codes should I use to report ASD?

    Clinicians should generally report at least two ICD-10 codes, one for the medical diagnosis and one or more for the speech-language disorder(s) being treated.

    The ICD-10-CM code for ASD—F84.0 (autistic disorder)—should be the physician’s or psychologist’s diagnosis (typically required by payers) of the underlying medical condition, documented in the patient’s medical record.

    Additional ICD-10-CM codes describe the language, cognitive and/or social communication disorder(s) that the provider is treating, such as R48.8 (other symbolic dysfunction).

    In the standard method of reporting, R48.8—the treating diagnosis—would be first, and F84.0 (autistic disorder) would be the supporting medical diagnosis.

    However, some payers may require clinicians to report F84.0 first and the treating diagnosis second. Others may require the speech-language-related codes in the F80 series (such as F80.2 for mixed receptive expressive language disorder) rather than R48.8. Clinicians should follow payer guidance. The key is to make sure the ASD diagnosis—and not just the treating diagnosis—is included.

    A new ICD-10-CM code describes an encounter for ASD screening (Z13.41). Z-codes describe factors other than diagnosed illness or injury that can influence health status and contact with health services. However, many payers do not recognize Z-codes, so clinicians should verify with their facility and/or payer before using this code.

    Find a complete list of ICD-10-CM codes for speech-language pathologists here.

    I reported F84.0 (autistic disorder) and a code from the R47 series (speech disturbances) and my claim was denied. Why?

    An exclusion note (Excludes1) on the R47 series indicates that nothing in that series may be reported with F84.

    In the case of an ASD-related speech disorder, clinicians should use F80.0 (phonological disorder) along with the ASD diagnosis. If the patient has both an articulation and a language disorder related to ASD, the claim could include R48.8 (Other symbolic dysfunction), F80.0 and F84.0.

    What ICD-10-CM code(s) should I use when ASD is suspected, but a formal diagnosis has not yet been made?

    Clinicians should report the F80 series of codes for developmental speech, language, cognitive and social communication disorders if a diagnosis of ASD has not been documented in the medical record. For example, report F80.82 for social pragmatic communication disorder or F80.2 for mixed receptive-expressive language disorder.

    After the ASD diagnosis is established and included in the medical record, clinicians may report R48.8 instead of the F80 series to reflect language, cognitive and social communication impairments due to an underlying medical condition.

    Can I report F80.82 (social pragmatic communication disorder) and ASD together?

    No, as insurers can deny claims with these codes reported together. An Excludes1 note associated with F80.82 prohibits reporting it with F84.0 (autistic disorder) or F84.5 (Asperger’s syndrome)—because a social communication disorder is considered inherent to ASD and Asperger’s syndrome. F80.82 is the only code in the F80 series that is excluded from reporting with ASD. SLPs may instead report R48.8 (other symbolic dysfunction) as the treating diagnosis for a social communication disorder associated with ASD.

    What about Excludes2 notes? Do they also affect which codes can be reported together?

    Excludes2 notes are confusing—despite their name, they do not exclude reporting of the listed codes. In fact, they specifically allow the listed codes to be reported together.

    Excludes2 notes indicate that the listed conditions may be reported together even though they are unrelated. For example, F80.1 (expressive language disorder) and F80.2 (mixed receptive-expressive language disorder) each have Excludes2 notes associated with the entire F84 series (pervasive developmental disorders, including ASD), meaning they may be billed together. Find more information on Excludes notes here.

    What procedure codes should I use to report ASD-related services?

    The CPT codes used to report all speech-language treatment are the same, regardless of the diagnosis. CPT codes reported on the claim should describe the service provided and should be supported by the ICD-10-CM codes describing the patient’s diagnosis.

    For example, CPT codes commonly used for evaluation and treatment of patients with ASD include 92523 (evaluation of speech sound production and language comprehension and expression), 92507 (individual speech, language, voice, communication treatment), and 92508 (group speech, language, voice, communication treatment). Other codes, however, describe different kinds of evaluation and treatment that may be provided to people with ASD: 92610 (clinical evaluation of swallowing function), 97127 (cognitive therapy) or 92526 (swallowing and feeding therapy), for example.

    Find more information on CPT codes for speech-language pathologists here.

    Can I use CPT code 92523 (speech and language evaluation) when I administer the Autism Diagnostic Observation Schedule (ADOS)?

    No. The ADOS does not specifically evaluate speech and language abilities. Clinicians may instead consider CPT codes 96112 and 96113 (standardized developmental test administration, first hour, and each additional 30 minutes). Check with payers to make sure SLPs may report these codes and independently establish an ASD diagnosis. Note that payers typically require a formal diagnosis of ASD from a physician or psychologist.

    Documentation should establish that this evaluation is separate and distinct from other services, such as a speech and language evaluation (92523). CPT codes 96112 and 96113 should not be billed in addition to 92523 or other speech-language services solely to capture that a standardized test was completed as part of the evaluation. CPT code 92523 represents a comprehensive evaluation of speech and language and includes both standardized and non-standardized testing.

    Find additional details on 96112 and 96113 here.

    Can SLPs report the new CPT codes related to adaptive behavior assessment (97151–97158)?

    The answer depends on the payer. Payers may specify which provider types are eligible to report these codes, as they often require the clinician to be trained in applied behavioral analysis (ABA). There are also limitations on billing these codes in conjunction with speech and language treatment codes. For more information, click here.

    Author Notes

    Neela Swanson is director of ASHA health care policy, coding and reimbursement.

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