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Autism Care Demonstration Medical Documentation Requirements

Providers are required to document the session time and presence or absence of the beneficiary in the claim notes, when applicable, on claims submitted for applied behavior analysis (ABA) services. (See Autism Care Demonstration Billing Details.) 

As per the TRICARE Operations Manual (Chapter 18, Section 4, Paragraph 17.2) and TRICARE Policy Manual (Chapter 1, Section 5.1), rendering clinicians must maintain narrative summaries that relate to the goals and objectives outlined in the beneficiary’s treatment plan. These narrative summaries, also referred to as session notes, must correspond to ABA claims filed for that beneficiary. Providers do not need to submit the session notes with the ABA claims; however, Health Net Federal Services, LLC (HNFS) may request them for claims payment during an audit. HNFS will compare the beneficiary’s session notes to the provider’s claims to verify all required documentation exists and is adequate to support the charges.
 

Category III CPT®  Codes 

(Dates of Service Prior to Jan. 1, 2019)

Category I CPT®  Codes 

(Dates of Service On or After Jan. 1, 2019)

Service
(Conditions for Use)
CPT® Code Required Documentation Services to be Performed By Service 
(Conditions for Use)
CPT® Code Required Documentation Services to be Performed By
Outcome Measures Performed by BCBA/
BCBA-D
T1023 The report (for example, written summary and scores)  Authorized ABA supervisor Outcome Measures Performed by BCBA/
BCBA-D
T1023 The report (for example, written summary and scores) BCBA, BCBA-D or Assistant Behavior Analyst
ABA Assessment and ABA Treatment Plan
Initial assessment (development of initial treatment plan) and six-month treatment plan updates
0359T
(untimed code)
The initial assessment report with all required elements in the TOM, Chapter 18, Section, 4, Paragraph 8.3  Authorized ABA supervisor or delegated assistant behavior analyst Behavior Identification Assessment
Initial assessment (development of initial treatment plan) and six-month treatment plan updates. Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
97151 (16 units)

A session note for each encounter billed for the initial assessment 

The narrative summary with all documented requirements in the TOM and TPM (Data collection is insufficient for a medical record.)

Summary should also include:

Content of the session to include what activity and measures were administered during the assessment. 

 

BCBA, BCBA-D  or Assistant Behavior Analyst
Adaptive Behavior Treatment by Protocol
One-on-one ABA interventions delivered per ABA treatment plan protocol (direct hands-on ABA services)
 

0364T
(initial 30 minutes per day) and

0365T
(each additional 30 minutes per day)

The narrative summary with all documented requirements in the TOM and TPM (Data collection is insufficient for a medical record.)

Summary should also include:

Child’s compliance with the targets; difficulties or issues with a specified target or goal; a description of what took place and the response; and anything notable about the child’s behavior, family changes, etc.

Assistant behavior analyst or behavior technician (tiered model) / authorized ABA supervisor (sole delivery model)

BCBA-Ds, BCBAs and BCaBAs can fill a shift for behavior technicians if they are ill or absent.

Adaptive Behavior Treatment by Protocol
Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes.

 

97153

The narrative summary with all documented requirements in the TOM and TPM (Data collection is insufficient for a medical record.)

Summary should also include:

Child’s compliance with the targets; difficulties or issues with a specified target or goal; a description of what took place and the response; and anything notable about the child’s behavior, family changes, etc.

 

BCBA, BCBA-D,  Assistant Behavior Analyst, or RBT

Observational Behavioral Follow-Up Assessment – Supervised Fieldwork
Direct supervision of every behavior technician must include at least two face-to-face, synchronous contacts per a 30 consecutive day period (one must be direct one-on-one observing the behavior technician or technicians providing the face-to-face).

At least one of the supervision sessions within the 30 consecutive day period, per beneficiary, individual or group, must be conducted in person (not remotely).

Group supervision: Direct observation supervision may take place in a group format whereby the authorized ABA supervisor observes each member of an ABA team delivering services, one at a time each taking turns.

0360T
(initial 30 minutes per day) and

0361T
(each additional 30 minutes per day)

The narrative summary with all documented requirements in the TOM and TPM 

The Behavior Analyst Certification Board's "BCBA/BCaBA Experience Standards" checklist is insufficient for medical record documentation.

Summary should also include:

Who was present; what was observed (as in the treatment fidelity for a technique or new skill or goal); and what feedback was given to the behavior technician.

Authorized ABA supervisor or delegated assistant behavior analyst N/A

Adaptive Behavior Treatment by Protocol Modification

When beneficiary is present:

One-on-one time with one beneficiary to develop a new or modified protocol; demonstrate a new or modified protocol to a behavior technician and/or parents/caregivers; and transition or discharge reassessments and treatment plan updates.

When beneficiary is not present:

Treatment team meetings where the authorized ABA supervisor, the parents/caregivers, the assistant behavior analysts, and/or behavior technicians meet as a team to discuss the treatment modifications.

0368T
(initial 30 minutes per day) and

0369T
(each additional 30 minutes per day)

The narrative summary with all documented requirements in the TOM and TPM 

Summary should also include:

Who was present; what was assessed, revised or observed during that session; and what was demonstrated to whom.

Authorized ABA supervisor or delegated assistant behavior analyst

Adaptive Behavior Treatment with  Protocol Modification
Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes.

 

97155

The narrative summary with all documented requirements in the TOM and TPM 

Summary should also include:

Who was present; what was assessed, revised or observed during that session; and what was demonstrated to whom.

BCBA, BCBA-D  or Assistant Behavior Analyst
Family Adaptive Behavior Treatment Guidance
TRICARE-eligible parent/caregiver training (beneficiary does not need to be present)
 
0370T
(untimed code)

The narrative summary with all documented requirements in the TOM and TPM 

Summary should also include:

Parent’s participation and understanding of the targets and interventions; any difficulties or issues with a specified target or goal; description of what took place and the response; and anything notable about behavior, family changes, etc.

Authorized ABA supervisor or delegated assistant behavior analyst Family Adaptive Behavior Treatment Guidance
Family adaptive behavior treatment guidance, administered by a physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s) /caregiver(s), each 15 minutes
97156

The narrative summary with all documented requirements in the TOM and TPM 

Summary should also include:

Parent’s participation and understanding of the targets and interventions; any difficulties or issues with a specified target or goal; description of what took place and the response; and anything notable about behavior, family changes, etc.

BCBA, BCBA-D  or Assistant Behavior Analyst

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