Progress notes

 

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.

Required progress notes elements

This list is not all-inclusive. Please review the TOM, Chapter 18, Section 4 and TRICARE Policy Manual (TPM), Chapter 1, Section 5.1 for complete details.

  • Beneficiary’s full name
  • Date and time of session to include start and end time
  • Location of rendered services
  • Length of session
  • Legible name of the rendering provider name, to include provider type/level
  • Signature of the rendering provider with the date signed
  • Name of authorized ABA supervisor
  • Name of all session participants (excluding other beneficiaries in CPT codes 97157 and 97158)
  • Summary of the beneficiary’s current clinical status evidenced by the beneficiary’s signs and symptoms
  • Narrative content of the session (group session may contain a common summary)
  • Summary of the techniques attempted during the session
  • Narrative description of the response to the treatment, the outcome of the treatment, and the response to significant others (group session notes must contain individualized responses to treatment)
  • Narrative statement summarizing the beneficiary’s degree of progress towards the treatment goals
  • Effective January 1, 2019, the final product for CPT code 97151 must be in the format of a TP. However, all encounters using CPT code 97151 must document a progress note. This progress note must include, but is not limited to:
    • The date and time of session to include start and end time;
    • Length of assessment session;
    • Legible name of the rendering provider, to include provider type/level;
    • A signature of the rendering provider
    • Content of the session to include what activity, measures, observations were administered during the assessment

Please note: Each section of the progress note documentation must be individualized to the beneficiary and each session.

Element details

Beneficiary name
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.

Location
The place of service (home, clinic/center, daycare (non-preschool), school, community, telemedicine).

Participants
Session participants name and relationship to the beneficiary must be documented. Do not include names of other beneficiaries.

Provider details
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.

Session content
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.

Description by CPT code
  • CPT 97151: Document what activity, measures, observations were administered during the assessment
  • CPT 97153: Include the domains targeted in the TP, examples of targets addressed, and highlight progress and barriers on individual targets as appropriate
  • CPT 97155: Document modifications in the program during the session (for example, changes to acquisition charts, progression of objectives/benchmarks, modification to procedures, and behavior intervention plan) and modeling of new or modified protocols to the BT and/or parents/caregivers
  • CPT 97156: Document ABA principles covered with the parent/guardian and progress toward parent/guardian goals. The note should describe recommendations the ABA supervisor or assistant behavior analyst provided to the parent/guardian on improving performance on parent goals, implementation of the behavior intervention plans and generalization of mastered skills outside of programming. When the beneficiary is present during parent training, the note should document what was modeled for the parent or what the parent implemented during the session and the feedback provided.
  • CPT 97157: Describe session content to include what ABA principles were covered in the group parent training, the specific skill acquisition and behavior reduction techniques that were reviewed, what was modeled and the feedback provided (if relevant)
  • CPT 97158: Describe what social deficit areas, skill acquisition targets and problem behaviors were addressed in the group session
  • CPT 99366 and 99368: Report participants’ with documentation of their role in the medical conference, contributed information and subsequent treatment recommendations

ABA techniques
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.

Common mistakes
  • Beneficiary’s full name missing
  • Provider’s full name and/or credentials missing
  • Date and signature of rendering provider missing
  • Name of authorized ABA supervisor missing
  • Length of session included separately from in/out times (in form of time and not units)
  • Location (i.e. home, clinic, office, school, telehealth) missing (GPS coordinates do not meet this requirement)
  • Rendering and billing providers do not match
  • Clinical status as defined by the Defense Health Agency (DHA) not included
  • Progress notes are illegible
  • Progress note for 97151 missing (TP alone does not meet this requirement, progress note required)
  • Misuse of 97155 for supervision/observation only
  • Protocol modification that occurred using 97155 not clearly defined in progress note
  • Narrative content missing in the following areas (data alone does not meet this requirement):
    • Summary of session
    • Response to treatment
    • Summarizing patient’s degree of progress towards goal
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