Key Takeaways
- Michigan, Virginia, Vermont, and Texas have each imposed restrictions on ABA billing codes, with Vermont’s January 2026 changes (discontinuing concurrent billing for treatment codes, restricting telehealth delivery, and introducing new supervision terminology) drawing the most alarm from providers.
- The 2019 CPT adaptive behavior code set (including codes 97153, 97155, and 97151) was designed to capture the layered structure of ABA therapy, where a supervising BCBA directs a technician’s work in real time. Concurrent billing restrictions, providers argue, treat these two distinct services as one.
- The ABA Coding Coalition (comprising the Association of Professional Behavior Analysts, the Behavior Analyst Certification Board, the Council of Autism Service Providers, and Autism Speaks) has sent letters to Medicaid programs and commercial insurers in all four states challenging the restrictions.
- Payer concerns about concurrent billing have surface logic: if a clinician and a technician both bill for simultaneous work with the same child, it can appear duplicative. Providers counter that the clinician’s real-time oversight and the technician’s direct treatment are complementary services, not redundant ones.
- Federal and state audits of ABA billing have uncovered genuine documentation failures across the industry, giving payers institutional justification for tighter scrutiny even when specific restrictions go further than the evidence warrants.
- The AMA’s CPT Editorial Panel approved revisions to the adaptive behavior code set in September 2025, with changes taking effect in January 2027. The specific language remains confidential under AMA rules, but the revisions are aimed at improving accuracy and consistency.
In the arcane lexicon of American healthcare, few phrases carry as much weight, or provoke as much confusion, as “concurrent billing.” To the uninitiated, the term sounds like an accountant’s abstraction, a matter of invoices and decimal points. But for the families of children with autism, and for the therapists who work with them, concurrent billing represents something far more concrete: the difference between a child receiving comprehensive treatment and a child receiving something less.
This winter, as states across the country have moved to restrict how providers bill for Applied Behavior Analysis (the therapy that has become the dominant treatment for autism spectrum disorder), a small but determined coalition has been pushing back. The ABA Coding Coalition, an alliance of professional organizations that helped create and now stewards the billing codes under scrutiny, has spent recent weeks firing off letters to Medicaid programs and commercial insurers in Michigan, Virginia, Vermont, and Texas, challenging what it views as misguided restrictions on the way autism services are delivered and documented. Those disputes land in a broader context: federal audits have already identified more than $120 million in improper ABA billing payments across Indiana, Wisconsin, and Maine, giving payers institutional cover for tightened scrutiny even when specific restrictions overshoot what the evidence warrants.
The disputes may seem technical (questions of how many hours a session note can cover, or whether two different services can be billed simultaneously) but they illuminate a deeper tension at the heart of American healthcare. On one side stand payers, both public and private, seeking to control costs and prevent fraud. On the other stand providers and families, arguing that bureaucratic restrictions are undermining care for one of the most vulnerable patient populations.
How ABA Billing Codes Work: The Structure Behind Concurrent Services
To understand the current battles, one must first understand the structure of ABA therapy itself. Unlike a physician’s office visit or a surgical procedure (discrete events with clear beginnings and endings), ABA is an intensive, ongoing intervention that can occupy twenty, thirty, or even forty hours of a child’s week. The therapy operates on multiple levels simultaneously: a behavior technician works directly with a child, implementing treatment protocols, while a supervising clinician (typically a Board Certified Behavior Analyst) observes, adjusts the treatment plan, and provides guidance in real time.
This layered structure is captured in a set of billing codes that took years to develop. In 2019, after extensive collaboration between professional organizations and the American Medical Association, a new code set for “adaptive behavior services” took effect. The codes distinguished between different types of work: 97153 for direct treatment by protocol, delivered by a technician; 97155 for treatment with protocol modification, provided by the supervising clinician; 97151 for assessment; 97156 for family guidance; and several others.
The Coalition that shepherded these codes into existence originally comprised the Association of Professional Behavior Analysts (APBA), Association for Behavior Analysis International (ABAI), and the Behavior Analyst Certification Board (BACB), with the Council of Autism Service Providers joining in 2019 after the codes took effect. Together, these organizations believed the new system would bring clarity and consistency to a field that had long operated in a billing wilderness. But standardization, as it turned out, did not mean harmony. In the years since, payers have interpreted the codes in ways that providers argue contradict both the letter and spirit of the code set’s design. And nowhere has this tension been more acute than in the question of concurrent billing.
ABA Billing Restrictions in Michigan, Virginia, Vermont, and Texas: What Changed
The Coalition (which now includes Autism Speaks in place of ABAI) has documented four distinct state-level variations on a common theme.
In Michigan, Blue Cross Blue Shield has imposed restrictions on documentation practices for direct treatment services, limiting the duration that a single session note can cover to no more than two hours and thirty minutes. For providers who may deliver four or five hours of treatment in a single day, the requirement to break documentation into multiple notes adds administrative burden without obvious clinical benefit. In Virginia, the state’s Department of Medical Assistance Services has restricted concurrent billing of assessment and treatment codes. Virginia Medicaid does allow concurrent billing of 97155 and 97153 for supervision activities when the clinician is directing a technician’s treatment and all three parties are present, but the boundaries of what qualifies remain subject to interpretation. In Texas, where Medicaid only began covering ABA services comprehensively in February 2022, the Coalition has raised concerns about restrictions on concurrent billing for protocol-based treatment and protocol modification services, as well as potential limitations on authorized hours. Indiana, another state where the Coalition has previously engaged Anthem over billing restrictions, provides a preview of how quickly payer policy can reshape provider operations when reimbursement models change rapidly.
Vermont has generated the most alarm. In November 2025, the Department of Vermont Health Access announced a series of policy changes effective January 1, 2026, that providers and families have characterized as severe. The changes include the discontinuation of concurrent billing for treatment codes, significant limitations on telehealth delivery (restricting which codes can be delivered remotely), and clarifications around supervision terminology that have left providers uncertain of compliance requirements. Vermont’s telehealth restrictions are particularly consequential given that the broader ABA telehealth landscape remains unsettled at both state and federal levels, with many providers having built service delivery models around remote supervision and caregiver coaching that were enabled during the pandemic and have not been formally codified.
A communications official for the Vermont department defended the changes to a local news outlet, framing them as necessary fiscal discipline. The policy aims to ensure, as the official put it, “that providers are not billing twice when we should be only paying for that service once.” But providers argue the changes misunderstand the nature of ABA treatment, where simultaneous oversight and direct care are not redundant but complementary: two essential layers of a single therapeutic intervention.
Why Payers Are Restricting ABA Concurrent Billing: The Fraud and Cost Context
The restrictions that have drawn the Coalition’s ire do not emerge from a vacuum. Payers face genuine pressures to control healthcare spending and prevent fraudulent billing. The ABA industry has grown exponentially in recent years, driven by increasing autism diagnoses, expanded insurance mandates, and significant private equity investment. Multi-state ABA platforms now command EBITDA multiples among the highest in behavioral health, and with that growth has come scrutiny. Federal OIG audits in Indiana, Wisconsin, and Maine have uncovered widespread documentation and billing failures, with the Maine audit alone identifying $45.6 million in improper payments. The Maine audit findings are part of a coordinated federal series that currently has four additional state investigations underway.
From a payer’s vantage point, concurrent billing restrictions can appear reasonable: if a supervising clinician and a technician are both billing for work with the same child at the same time, is the state not paying twice for one service? The question has surface logic. But ABA providers argue it reflects a fundamental misunderstanding of how effective treatment works. The clinician’s real-time guidance shapes and improves the technician’s intervention, producing outcomes neither could achieve independently. The codes were designed precisely to capture this distinction, not to obscure it.
The ABA Coding Coalition’s Response: Letters, Advocacy, and a Long Record of Engagement
The Coalition finds itself in a peculiar position. Having labored for years to create a standardized billing framework, it now must defend that framework against interpretations it views as misguided. This is not the first time. The Coalition has previously engaged with the Centers for Medicare and Medicaid Services over medically unlikely edits that it felt inappropriately limited daily service units, and with Anthem over rate reductions and concurrent billing restrictions in Indiana, Ohio, and Texas.
Antitrust laws prevent professional organizations from negotiating reimbursement rates directly, but advocacy for appropriate policy implementation remains permissible. So the Coalition writes letters. It submits public comments. It encourages providers to use its contact portal to report problematic payer practices. It works, in other words, through the incremental channels available to it. Whether these efforts will succeed remains uncertain. The Coalition’s January announcement noted that it would “update providers on any developments,” a phrase that suggests awareness of how slowly such matters resolve. Policy changes, once implemented, tend to be sticky. And states facing budget pressures may be reluctant to reverse restrictions that promise cost savings, however contested those savings may be.
What ABA Billing Restrictions Mean for Families and Access to Care
Behind the billing codes and policy disputes are children and families navigating a healthcare system that often seems designed to confound them. The restrictions at issue in Michigan, Virginia, Vermont, and Texas may seem like technical matters (questions of documentation format or billing simultaneity) but they carry real consequences. A provider burdened with excessive paperwork has less time for treatment. A clinician prohibited from billing for concurrent oversight may reduce supervision or absorb the cost, neither option sustainable in the long term. And a family whose Medicaid program restricts telehealth delivery may face impossible choices about transportation and scheduling in states where providers are scarce. As payers and policymakers push the autism care industry toward greater accountability, the risk is that cost-control mechanisms designed to address genuine billing abuses end up reducing access to the layered clinical model that makes ABA effective in the first place.
The Coalition’s advocacy, then, is not merely a defense of its members’ economic interests (though it is certainly that) but an argument about what autism treatment requires. The codes that the Coalition helped create were designed to capture the complexity of ABA’s layered approach: assessment informing treatment, treatment guided by supervision, supervision documented and billed as the distinct professional service it is. To flatten this structure in the name of cost control, the Coalition argues, is to misunderstand the nature of the care.
ABA CPT Code Changes Coming in 2027: What Providers Need to Know
The ABA Coding Coalition has invited providers experiencing problematic payer practices to submit concerns through its website’s contact feature, signaling an intent to continue monitoring and responding to state-by-state developments. Meanwhile, the billing code framework itself is evolving: in September 2025, the AMA’s CPT Editorial Panel approved revisions to the adaptive behavior code set, changes that will take effect in January 2027. The specific language of these updates remains confidential under AMA rules, but the announcement suggested refinements aimed at improving accuracy and consistency.
For now, the Coalition’s letters have been sent, the comments submitted, the case made. Whether Medicaid programs in Michigan, Virginia, Vermont, and Texas will reconsider their policies remains to be seen. The wheels of healthcare administration turn slowly, and the interests at stake (provider reimbursement, state budgets, patient access) are not easily reconciled. What is clear is that the language of billing codes carries weight far beyond the claims processing systems where they circulate. In the gap between a code’s intended meaning and a payer’s interpretation lies the space where care is shaped, limited, or denied. The ABA Coding Coalition, having written the codes, now finds itself defending the vision they were meant to encode: a therapy delivered in layers, documented with precision, and paid for in full.
Frequently Asked Questions
What is concurrent billing in ABA therapy?
Concurrent billing in ABA refers to the practice of submitting claims for two distinct services delivered at the same time to the same patient: typically, a behavior technician’s direct treatment session (billed under CPT 97153) and a supervising BCBA’s simultaneous oversight and protocol modification work (billed under CPT 97155). Providers argue these are separate professional services that produce better outcomes together than either would alone. Some payers have restricted this practice on the grounds that it constitutes double billing for a single service, a characterization the ABA Coding Coalition disputes as a misreading of the code set’s design.
What are the main ABA CPT billing codes, and what does each cover?
The core ABA adaptive behavior codes introduced in 2019 are: 97153 (adaptive behavior treatment by protocol, delivered by a technician under supervision); 97155 (adaptive behavior treatment with protocol modification, provided by the supervising clinician, typically a BCBA); 97151 (behavior identification assessment, conducted by the supervising clinician); 97156 (family adaptive behavior treatment guidance, provided to caregivers); 97152 (behavior identification supporting assessment, administered by a technician under supervision); and 97158 (group adaptive behavior treatment by protocol). Each code was designed to capture a distinct type of professional work within ABA’s layered clinical model.
Which states are currently restricting ABA concurrent billing?
As of early 2026, the ABA Coding Coalition has identified four states with active restrictions: Michigan (where Blue Cross Blue Shield limits single session notes to no more than two hours and thirty minutes); Virginia (where Medicaid has restricted concurrent billing of assessment and treatment codes, though concurrent billing of 97155 and 97153 remains permitted under specific supervision conditions); Texas (where the Coalition has raised concerns about concurrent billing restrictions and authorized hour limitations under Medicaid, which only began comprehensive ABA coverage in February 2022); and Vermont (which implemented the most sweeping changes effective January 1, 2026, including discontinuing concurrent billing for treatment codes and restricting telehealth delivery of ABA services). The Coalition has also previously engaged with payers in Indiana, Ohio, and other states over similar issues. For context on how Indiana’s Medicaid ABA policies have evolved, Acuity has covered those developments in depth.
What is the ABA Coding Coalition and who does it represent?
The ABA Coding Coalition is an alliance of professional organizations that collaborated to develop the 2019 CPT adaptive behavior code set and now advocates for its appropriate implementation by payers and government programs. Current members include the Association of Professional Behavior Analysts (APBA), the Behavior Analyst Certification Board (BACB), the Council of Autism Service Providers (CASP), and Autism Speaks. The Association for Behavior Analysis International (ABAI) was an original founding member but has since been replaced by Autism Speaks. The Coalition monitors payer policies, submits public comments, engages with Medicaid programs and commercial insurers, and maintains a provider portal for reporting problematic billing practices.
What ABA billing code changes are coming in 2027?
In September 2025, the American Medical Association’s CPT Editorial Panel approved revisions to the adaptive behavior service code set that will take effect in January 2027. The specific language of the revisions remains confidential under AMA rules pending official publication. The announcement described the changes as aimed at improving accuracy and consistency in how ABA services are described and billed. Providers should monitor AMA CPT publications and Coalition communications for guidance on how the updated codes will affect documentation and billing practices.
Why have ABA billing audits increased, and what do they mean for providers?
ABA billing has come under increased federal and state audit scrutiny as Medicaid spending on autism therapy has grown dramatically, rising from around $660 million nationally in 2019 to $2.2 billion in 2023, according to a Wall Street Journal analysis. Federal OIG audits in Indiana, Wisconsin, and Maine have identified more than $120 million in confirmed improper payments, with auditors citing documentation failures, missing credentials, unsupported billing units, and in some cases services billed during holidays or for more than twenty-four hours in a single day. These findings have given payers broader justification for tighter utilization management and billing restrictions, even in cases where specific restrictions go beyond what the audit evidence directly supports. For providers, the practical implication is that documentation practices once considered adequate may no longer withstand scrutiny. Session notes must explicitly describe the services provided, supervision must be documented contemporaneously, and billing must precisely reflect the time and nature of services delivered.
