Medical Coding Guidelines & Tips for Coding and Billing Autism Spectrum Disorder (ASD)
Autism Spectrum Disorder (ASD) is a neurodevelopmental condition that impacts communication, behavior, and social interaction. As the diagnosis rate rises and services expand, it’s crucial for medical coders and billers to apply accurate, compliant coding to ensure appropriate reimbursement and documentation. This blog provides essential guidelines and tips for coding and billing for autism-related services.
Understanding Autism Spectrum Disorder in Medical Coding
ICD-10-CM Diagnosis Codes for Autism
The primary code for ASD is found in the F84 category:
F84.0 – Autistic disorder
F84.5 – Asperger’s syndrome
F84.8 – Other pervasive developmental disorders
F84.9 – Pervasive developmental disorder, unspecified
Use the most specific code available. For example, if the provider documents classic autism, F84.0 is appropriate. If the exact type is not clear, use F84.9.
Coding for Services Related to Autism
Patients with ASD often require a range of services. Here are commonly billed services and their associated CPT codes:
Evaluation and Management (E/M) Services
99202–99215 – Office or other outpatient E/M services
Use based on time or medical decision-making. Document comorbidities and complexity, which are common with ASD (e.g., ADHD, anxiety, seizures).
E/M https://codingclarified.com/e-m-2025/
Developmental & Behavioral Assessments
96110 – Developmental screening (e.g., M-CHAT)
Often used in pediatric offices as part of routine well-child visits.96112 & 96113 – Developmental test administration (2+ units for extended time)
96116 – Neurobehavioral status exam
96130–96133 – Psychological testing evaluation and services
96136–96139 – Test administration and scoring by a psychologist or technician
Use modifier 59 if multiple assessments are performed on the same date.
Applied Behavior Analysis (ABA) Services
(Used frequently for children diagnosed with ASD)
97151 – Behavior identification assessment (by QHP)
97153 – Adaptive behavior treatment by technician
97155 – Adaptive behavior treatment with protocol modification
97156–97158 – Family or group adaptive behavior therapy
Confirm if your state Medicaid program or private insurer requires specific provider credentials (e.g., BCBA) or authorization.
Billing Guidelines and Considerations
Documentation Essentials
Clear diagnosis of ASD, supported by DSM-5 criteria
Type of service (assessment, ABA therapy, counseling, etc.)
Start/stop times for time-based codes
Clinical notes showing medical necessity and progress
Prior Authorization
Many payers require prior authorization for ABA therapy and psychological testing. Always verify requirements before delivering services.
Telehealth Services
With the rise of telehealth, many autism-related services are now billable remotely:
Use Place of Service 02 or 10 and appropriate telehealth modifiers (95, GT).
Confirm that the payer allows specific codes to be billed via telehealth (especially ABA services).
Telehealth https://codingclarified.com/telehealth/
Common Coding Pitfalls to Avoid
Undercoding by using unspecified codes like F84.9 when a more specific code applies
Unbundling assessment services that are meant to be billed together
Missing documentation for time-based services or assessments
Using incorrect provider type (e.g., ABA therapy billed under a non-qualified provider)
Neglecting payer-specific modifiers for ABA therapy or psychological testing
Best Practices and Tips
Use Tools Like M-CHAT or ADOS and document their results for screening and assessment codes.
Stay Updated on payer-specific ABA requirements—each insurer may have unique billing protocols.
Coordinate with Clinical Staff to ensure notes match the level of service billed.
Audit Regularly for code accuracy, authorization tracking, and modifier usage.
Document Progress for therapy to show continued medical necessity.
Autism care is multifaceted and often long-term, requiring accurate documentation, correct use of CPT/ICD-10 codes, and attention to payer-specific rules. By following proper coding and billing guidelines, providers can ensure reimbursement for vital services that support individuals with ASD and their families.
ASD Related Services https://leader.pubs.asha.org/doi/10.1044/leader.BML.24052019.32#:~:text=The%20ICD%2D10%2DCM%20code,in%20the%20patient’s%20medical%20record.
