EIDBI billing codes in Minnesota: 97151 to 97157, 0373T, and the 97155 rule

EIDBI billing codes in Minnesota are a short list, but the rules around them changed on January 1, 2026. Early Intensive Developmental and Behavioral Intervention (EIDBI) is billed to Minnesota Health Care Programs (MHCP) under CPT codes 97151, 97153, 97154, 97155, 97156, and 97157, plus Category III code 0373T, each with the UB modifier and, for the CPT codes, in 15-minute units.

The code that draws the most scrutiny is 97155, observation and direction. The Department of Human Services (DHS) now expects authorized 97155 to be about 20% of the person's total intervention time on 97153, 97154, and 0373T, and every 97155 authorization request for services on or after January 1, 2026 must include individual clinical justification. Authorization reviews also run on tighter timelines, and DHS has clarified when billing must pause.

This guide covers each code, units and the midpoint rule, modifiers, authorization, telehealth, and the denial reasons that follow from getting any of those wrong. It does not state rates; use the current DHS EIDBI billing grid for that. Provider qualifications are in the EIDBI provider requirements guide, and the What is EIDBI guide explains the benefit these codes pay for.

The EIDBI billing grid codes

The DHS EIDBI billing grid (document dhs16_195657) lists each service, its procedure code, modifiers, units, and person and provider limits. The codes below are the ones health plans and DHS list as subject to the UB modifier requirement.

The CMDE line, 97151, is billed by the CMDE provider under their own enrollment and can be submitted once per calendar year without a service agreement; the EIDBI CMDE guide covers who can perform it and how it is reviewed. Two clarifications from January 2026 matter for the table. The 0373T line can be billed by only one provider even when several providers deliver the service, and the service must be delivered under the supervision of a Level I provider or a qualified supervising professional (QSP). DHS also updated the language on 97151 and T1024 to clarify eligible provider types, so check the grid rather than an older copy.

Group codes have their own limits. A daily limit on the grid is the maximum allowable billing for one day, not a target, and every unit must be medically necessary and supported by the individual treatment plan (ITP).

Units, the midpoint rule, and when billing must pause

For 97151, 97153, 97154, 97155, 97156, and 97157, one unit is 15 minutes. Minnesota follows the Centers for Medicare & Medicaid Services midpoint rule: a unit may be billed only when more than half of it, meaning 8 minutes or more, has been delivered during continuous service. If the total face-to-face time is under 8 minutes, the unit is not billable.

DHS provider news from December 5, 2025 added a second rule that is easy to miss. Providers may bill only while medically necessary services are being actively delivered by a provider who is present and engaged with the person and working on ITP goals. Billing must pause whenever delivery stops, including provider breaks for restroom use, meals or snacks, phone calls, administrative tasks, or stepping away for any reason. Midpoint billing applies only when the session is uninterrupted apart from brief treatment-related pauses. DHS and other auditors may recoup payment for time billed without active delivery.

Audit tip: a session note that shows one start time and one stop time for a four-hour block, with no record of breaks, is now a liability. Capture each service segment with its own clock times so the units on the claim match minutes of active delivery.

Modifiers: UB on everything, no level modifiers

The UB modifier is required on every EIDBI procedure code. Blue Cross and Blue Shield of Minnesota's bulletin P55R1-21 lists the affected codes as 0373T, 97151, 97153, 97154, 97155, 97156, 97157, H0032, H0046, and T1024, and HealthPartners' billing tips repeat the same requirement. Other modifiers are added only when they accurately describe the service, for example a telehealth modifier on a telehealth session.

Provider level is not a modifier. DHS provider news dated January 20, 2026 states that EIDBI provider specialty codes are programmed in MMIS during enrollment to designate Level I, II, or III, that they are not modifiers, and that providers must not enter them on claims. Agencies may use the specialty codes internally to verify that a provider's level matches the service being billed.

What the claim must carry instead is the right people. All EIDBI services are billed by, and provided by or under the clinical supervision of, a QSP who assumes professional responsibility for Level I, II, and III providers. On the 837P, HealthPartners asks for the rendering provider in loop 2310B and the supervising QSP in loop 2310D, with line-level rendering and supervising loops (2420A and 2420D) when more than one rendering provider appears on one claim. Fee-for-service claims go through MN-ITS or an 837P batch.

The 97155 rule: 20% and clinical justification

Observation and direction is the code DHS, its medical review agent, and managed care organizations (MCOs) are enforcing most consistently. The December 2025 clarification and the January 2026 billing grid update together say:

• Authorized 97155 requested in the ITP must generally be about 20% of total intervention time on 97153, 97154, and 0373T, in line with Council of Autism Service Providers and ABA Coding Coalition guidance.
• For EIDBI services requested on or after January 1, 2026, 97155 authorization requests must include individual clinical justification that demonstrates medical necessity. Observation and direction must be individualized and tied to the person's documented clinical need.
• If 97155 exceeds 20% of direct treatment hours, the medical review agent may request unit reductions or additional documentation.
• Providers must not deliver 97155 without prior authorization, must not request 97155 equal to or greater than direct treatment hours, and must not use it as a substitute for direct treatment, to mirror treatment intensity, or as a default agency practice.
• The QSP does not have to deliver all observation and direction; other qualified staff may provide it when clinically necessary.

The justification lives in the ITP. DHS points providers to the "How to complete ITP and Progress Monitoring" instructions for form DHS-7109. The EIDBI documentation guide covers what the ITP should say about supervision.

Authorization requests and review timelines

EIDBI requires authorization. For fee-for-service Medical Assistance, Acentra Health is the medical review agent. Effective January 1, 2026:

MCOs align their authorization rules with DHS guidance; Blue Cross, for example, requires the completed ITP form with initial, six-month, and annual authorization requests. Whichever payer is involved, the request has to match the ITP, and the ITP has to show the frequency, intensity, and duration of each service, including the 97155 justification.

One more January 1, 2026 rule affects what can be requested. EIDBI providers must not deliver or bill 97153, 97154, or 0373T during homeschool or online (virtual) school instruction. Family or caregiver training under 97156 remains covered during that time if the parent or caregiver is present and participates.

Telehealth billing

Minn. Stat. § 256B.0949, subd. 13 covers medically necessary EIDBI services and consultations delivered via telehealth in the same manner as in-person services, with the same thresholds, rates, and authorization requirements. Individual providers who plan to deliver telehealth self-attest that they meet the MHCP telehealth policy. On the claim, use the telehealth place of service and modifier the MHCP telehealth policy specifies; MHCP does not pay connection, origination, set-up, or site fees, and telehealth modifiers must not be used for services that are not real-time and client-facing.

The statute also limits telehealth for supervision. Required monthly observation and direction may be delivered via telehealth, but no more than two consecutive monthly sessions may be.

Common EIDBI denial reasons

Most EIDBI denials and recoupments trace back to one of these:

1. Missing UB modifier or a provider level code entered as a modifier.
2. No authorization, or units billed beyond the authorized amount for the code (remittances show an authorization-exceeded adjustment).
3. 97155 out of proportion to 97153, 97154, and 0373T, with no justification in the ITP.
4. Wrong or missing rendering or supervising provider, including a QSP who was not an agency employee on the date of service or a provider without a completed background study for that location.
5. Units that do not match the note: fewer than 8 minutes billed as a unit, or breaks billed as service time.
6. Date ranges on the claim that include days with no service; bill only the dates services were delivered.
7. Direct intervention during homeschool or online school on or after January 1, 2026.
8. Pre-payment review holds. EIDBI is one of 14 high-risk services whose claims can be held for record review before payment under the process DHS announced on October 29, 2025.

The MHCP claim denials guide explains how to read the 835 remittance codes and when an MCO appeal must be filed.

How Trustora helps

Trustora's EIDBI claims workflow builds each 837P line from the session record rather than from a manual entry screen. Units are calculated from the clock times of active delivery, the UB modifier is applied automatically, the rendering provider and supervising QSP are populated from the staff record, and a pre-claim compliance gate stops a line when the provider level, authorization units, or 97155 proportion do not match the ITP.

Authorization tracking shows remaining units per code and flags a pended request against the 10-calendar-day response window. ERA and remittance reconciliation posts payments and denials back to the session, and denied lines can be corrected and resubmitted or assembled into an appeal packet. See the platform overview for the full claims lifecycle.