This guidance outlines essential information for progress notes per the requirements in TRICARE Operations Manual (TOM), Chapter 18, Section 4, Department of Defense (DoD) Autism Care Demonstration (ACD). ABA providers are required to maintain progress notes (also referred to as session notes or narrative summaries) that relate to the goals and objectives outlined in the beneficiary’s Treatment Plan (TP). These notes must correspond to Applied Behavior Analysis (ABA) claims filed for that beneficiary. Providers do not need to submit progress notes with claims; however, Humana Military will request them during ABA quality monitoring and oversight audits (reference TOM paragraph 8.9 for requirements). Humana Military will compare the progress note(s) to the provider’s claims to verify documentation compliance and the adequacy to support the billed charges.
Please note: Each section of the progress note documentation must be individualized to the beneficiary and each session.
The full name of the beneficiary is required. Initials do not meet the requirement.
Date/Time/Length of session
Date and start and end times of each session is documented including the length of the session. The use of military time is not necessary when completing progress notes.
The place of service (home, clinic/center, daycare (non-preschool), school, community, telemedicine).
Session participants name and relationship to the beneficiary must be documented. Do not include names of other beneficiaries.
Include the name and credentials of the rendering ABA supervisor, assistant behavior analyst or Behavior Technician (BT), with a dated signature. If the ABA supervisor is not the rendering provider, their name must be included in the note.
Current clinical status
The clinical status of the beneficiary is the specific, observable and measurable behavior displayed by the beneficiary at the beginning of treatment that indicate his/her readiness for learning, presence of antecedents to target behaviors and setting events. These items typically influence the application of ABA principles throughout the session, including the frequency and type of preference assessments, behavior momentum, type of teaching techniques utilized, modifications to the environment and possible impact on performance. The diagnostic criteria for Autism Spectrum Disorder (ASD), such as communication, socialization and repetitive behavior are not sufficient for clinical status.
The narrative summary should indicate the primary areas targeted from the TP, describe the barriers to performance and be representative of the duration of time filed on of the claim. A session note for a six-hour session would require greater content than a two-hour session. The documentation of all programs implemented within the session is not required; however, the session notes should support and justify the billable claim and include a strong representation of the ABA program implemented for the duration of the session. The note should cover, at a minimum, the domains targeted in the TP along with highlighting progress and barriers on individual targets as appropriate. The notes should be individualized and reflect that active delivery of an ABA program was implemented for the full duration of the session. Session notes for beneficiaries who are receiving ABA intervention in a school setting should be representative of the goals in the TP and demonstrate the active delivery of ABA techniques for the duration of the session. The presence of individual data points, lists of targets or goals with performance data (for example, 60 percent), tally marks, circled responses alone (for example, positive, negative, present or not present) are not a substitution for a narrative description.
ABA techniques such as Discrete Trial Training (DTT), chaining and prompting can be listed or marked in a check box. The session notes should highlight how changes in teaching techniques (for example, increasing prompt level or new error correction procedures) are being implemented within the content of the session, with a statement summarizing the techniques attempted during the session.
Response to treatment
The narrative description should include of how the beneficiary responded within the current session given the implementation of the TP goals. The narrative should focus on areas of strong performance and provide an explanation of barriers to performance where the beneficiary did not meet mastery criteria. Individual data points are not sufficient. The narrative description should also describe the outcome of the treatment, and the response to significant others (group session notes must contain individualized responses to treatment).
Progress towards goals
A narrative statement summarizing the beneficiary's degree of progress towards the treatment goals is needed. Session notes for 97153 should indicate the progress the beneficiary is making within the current session or as compared to the prior session with the same individual. When 97153 is rendered by behavior technicians, they are not expected to report on progress over time; however, it is within their scope to compare their last session with the current session, report on progress toward the individual goal, and highlight for the ABA supervisor BT’s. Session notes for 97155 completed by an ABA supervisor or assistant behavior analyst can report on progress over time on the goal to date and identify barriers to the anticipated acquisition rate. The session note should include any goals that are met and any progress towards discharge, and each section of the progress note documentation must be individualized to the beneficiary and each session.