South Carolina Ended Telehealth for 97151 — and Won't Accept a Telehealth Diagnosis

Two of South Carolina's pandemic-era telehealth flexibilities became permanent on July 1, 2026. One was withdrawn. The withdrawn one sits at the front of every case you open.

What changed, by code

• 97151, Behavior Identification Assessment — telehealth delivery “will no longer be allowable.” The manual is blunt: “The BIA cannot be completed via telehealth.” It must be administered in person with the member and caregiver, by a BCBA-D, BCBA or BCaBA.
• 97156, Family Adaptive Behavior Treatment Guidance — permanently incorporated as telehealth-eligible.
• 97155, Adaptive Behavior Treatment with Protocol Modification — permanently incorporated, with prior authorization required. The manual expects it in person and states it “will not be reimbursed through telehealth on a routine basis and not without prior authorization.” Treatment plans must carry clinical justification for use of the GT modifier on 25% of planned 97155 units.
• Asynchronous telehealth remains on the non-covered list for ASD services, reimbursable only for interprofessional consultations.

The rule that reaches further back than your codes

Separately from the code changes, the manual states that ASD diagnoses conferred by telehealth are not considered valid, and that autism measures and tests administered via telehealth — or reports resulting from telehealth evaluations — are not valid for determining medical necessity for ASD services.

That reaches children already in treatment. A child whose diagnosis came from a telehealth evaluation didn't lose the diagnosis, but the record supporting South Carolina Medicaid eligibility for ABA is one the manual no longer accepts, and no amount of later documentation converts a telehealth evaluation into an in-person one.

The other thing to know about 97151

The BIA doesn't require prior authorization — but claims are subject to post-payment review and recoupment if the member doesn't begin treatment under 97153 within one month of the assessment being completed, or if the services delivered aren't the ones the BIA and plan of care identified as medically necessary. An unauthorized code with a recoupment trigger is a code you want documented as carefully as an authorized one.

The limits

SCDHHS attributes the telehealth changes to its evaluation of utilization data, clinical evidence and provider feedback, and doesn't publish the underlying analysis. Managed care organizations administer authorization, coverage and reimbursement for their enrolled members, so an MCO may apply the 97155 prior-authorization requirement more tightly than the manual reads. And the manual doesn't say what happens to an authorization already running on a telehealth-based diagnosis.

What you must know or do

• Intake: stop scheduling 97151 by telehealth today, and check whether any BIA billed for a date of service on or after July 1 was delivered remotely. Those are recoupable.
• Clinical directors: pull every South Carolina Medicaid member who started since July 1 and identify which diagnoses came from telehealth evaluations. Ask the MCO how it wants those handled before it asks you.
• Billers: check your 97151 claims against the start date of 97153 for the same member. Anything where treatment didn't begin within a month of the assessment is exposed to post-payment review.
• Anyone using the GT modifier on 97155: the justification belongs in the treatment plan, not in an appeal. If a plan proposes telehealth for a quarter of planned 97155 units without that justification written in, add it before the next authorization.