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Behavioral Analysis (BA) Providers: NCCI Rules Apply to Medicaid

Date: 08/18/25

Sunshine Health reminds Behavioral Analysis (BA) providers about this important rule:

Medicaid claims are subject to National Correct Coding Initiative (NCCI) rules, which prohibit billing multiple services that are considered overlapping or duplicative on the same day, unless an appropriate modifier is used.

Providers should continue to bill with a minimum charge of $0.01 to ensure claim acceptance for codes 97153-XP and 97155-XP. This minimal billing prevents claim denials while maintaining compliance. As you continue to utilize the XP modifier for these codes, please ensure all documentation supports the services provided.

Claims lacking the correct XP modifier may trigger denials due to perceived duplication. The XP modifier clarifies that each service is distinct.

Proper application of XP requires:

  • Clear documentation showing who performed each service, including provider credentials and specialty.
  • Evidence that the services are separate and not overlapping in purpose or timing.
  • Supporting notes that distinguish practitioner roles, particularly crucial for Behavioral Analysts supervising RBTs or co-treating with another clinician. 

Failing to document thoroughly can result in claim audits or denial, even if the XP modifier is utilized correctly.

What products does this apply to?

  • Sunshine Health Medicaid (MMA)
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
  • Children’s Medical Services (CMS) Health Plan

Behavior Analysis (BA) Resources

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

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