Legal authority

CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), Minn. Stat. §256B.0949

Definitions

Observation and direction (also known as adaptive behavior treatment with protocol modification): An EIDBI service provided by a qualified EIDBI provider that covers the clinical direction and oversight of intervention services and active protocol modification of the person’s individualized treatment programming based on real-time observations.

Protocol modification: Ongoing clinical decision-making and adjustments made by a qualified EIDBI provider to ensure that treatment remains individualized, effective and responsive to the person’s progress or needs.

Observation and assessment: A component of protocol modification during which a qualified EIDBI provider observes service delivery with active evaluation of program component effectiveness for the person. The provider must:

Overview

Observation and direction:

A qualified EIDBI provider should bill for observation and direction when they do either of the following:

1. Conduct direct intervention with protocol modification(s) with the person (with no other EIDBI provider present) to observe changes in the person’s behavior or troubleshoot treatment procedures.

2. Join the person and another EIDBI provider during an individual, group or higher intensity intervention session with protocol modification(s).

Eligible providers

The following EIDBI providers can deliver and bill for observation and direction:

QSPs are responsible for clinical oversight regardless of which staff member delivers observation and direction.

Qualified level I and level II providers may deliver observation and direction when clinically appropriate and within their scope of practice.

A lower-level provider cannot deliver observation and direction to a higher-level provider.

Level I providers and level II providers who have not met their respective required experience threshold must receive observation and direction from a QSP to count the hours toward their required hours of supervised experience.

Multiple providers

Multiple providers may deliver non-duplicative observation and direction services at the same time, when clinically necessary, based on the person’s needs and documented in their ITP. Providers must follow the billing guidelines in the service authorization and billing section below.

Observation and direction covered services requirements

Observation and direction requirements for active engagement and protocol modification

Observation and direction covered services must include:

1. Active engagement with the person in assessment or treatment, including:

2. Protocol modification, which must:

Protocol modification includes, but is not limited to:

1. Modifications or revisions to specific components of a person’s procedure or treatment objectives, such as:

2. Observation and assessment to determine if the program components function effectively for the person or if they require revisions. For more information, refer to the observation and assessment section below.
Note: Observation without active assessment or data-driven justification is not a covered service.

3. Active direction or feedback to an EIDBI provider while that provider delivers a service (e.g., intervention). Direction or feedback may include:

4. Program implementation by a qualified EIDBI provider with the person to either:

Observation and assessment

As part of protocol modification, providers may conduct observation and assessment to determine if program components:

During observation and assessment, the provider must:

Note: Even if programming is effective, providers must support their decision with data and next steps.

Frequency of protocol modification

Regular modifications to treatment protocols are expected as the person makes progress toward goals. Treatment protocols also need changes when progress is absent or occurs at a slower rate than expected. Generally, if visual data analysis indicates that the person made inadequate progress over three sessions, the provider must try to identify the cause(s).

Training

Observation and direction only includes training when the training activity:

Non-covered services

Observation and direction does not include:

EIDBI providers must NOT:

Secondary information

Supervision

EIDBI providers must meet supervision requirements in Minn. Stat. §256B.0949, subd. 15-16, including ensuring the QSP provides required oversight.

All providers must:

For more information, refer to EIDBI – Clinical supervision.

Case notes

Providers must follow the instructions on EIDBI – Health service records to document observation and direction in the person’s case notes. They also must include the following active clinical engagement documentation specific to observation and direction:

Documentation requirements

When requesting observation and direction, the ITP must document:

Note: If requested observation and direction exceeds 20% of overall direct treatment hours, managed care organizations (MCOs) or the medical review agent may:

Observation and direction case note documentation training

Provider agencies must ensure individual providers delivering observation and direction receive training on how to thoroughly and accurately document session case notes.

Observation and direction case notes for multiple providers

When multiple providers deliver observation and direction at the same time as clinically necessary, all providers that bill for EIDBI services must complete their own case notes. They must clearly document distinct roles and activities to justify the need for simultaneous billing of the service.

For more information about case notes, refer to EIDBI – Health service records.

Telehealth

If medically appropriate to the person’s condition and needs, providers may deliver observation and direction via two-way, interactive video. For more information, refer to EIDBI – Telehealth services.

Note: The clinical supervisor may only deliver observation and direction via telehealth for two consecutive months. They must deliver observation and direction in person in the third month.

Service authorization and billing

For authorization and billing information, including provider and service limits, refer to:

Observation and direction authorization expectations

DHS expects EIDBI providers to align authorization requests and observation and direction service delivery with national best practices, including guidance from the Council of Autism Service Providers (CASP) and the ABA Coding Coalition. These organizations recommend that providers do not deliver observation and direction that exceeds 20% of a person’s direct treatment hours (i.e., CPT 97153, 97154 and 0373T). DHS enforces these expectations to support equitable, person-centered care and appropriate use of services.

Authorization and billing requirements

Not all supervision is billable under observation and direction. Refer to the observation and direction covered services requirements section above.

Provider responsibilities

EIDBI providers must authorize observation and direction:

Modification of written protocol

Modification of written protocols is an indirect service for which the provider cannot report or bill separately. The reimbursement rate for direct time with the person factors in time for a provider to complete administrative tasks (e.g., creating materials, modifying written protocols).

Multiple providers

When multiple providers deliver observation and direction at the same time, as clinically necessary, they may use the same billing code (i.e., 97155) to bill for observation and direction.

For example, a level I provider and QSP both deliver observation and direction (i.e., billing code 97155) while a level III provider delivers individual intervention services (i.e., billing code 97153). Both the level I provider and the QSP may use billing code 97155 to bill for observation and direction if: