As per the TRICARE Operations Manual (TOM) and TRICARE Policy Manual (TPM), 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 applied behavior analysis (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.
The TOM and TPM specify the required elements providers must include in session notes for services rendered under TRICARE's Autism Care Demonstration. Below are general recommendations on some of the key requirements to help ensure providers maintain complete session notes. This list is not all-inclusive. Please review TOM Chapter 18, Section 4, Paragraph 17.2 and TPM Chapter 1, Section 5.1 for additional information.
ABA providers are permitted to design individual templates to meet the needs of the session notes requirements. HNFS does not provide or create general templates.
The full name of the beneficiary is required when submitting the session notes. The initials or a number identifying the beneficiary will not be accepted.
The TOM specifically indicates a narrative description for each session is required. The presence of individual data points, lists of targets or goals with performance data (for example, 80 percent), tally marks, circled responses (for example, positive, negative, present or not present) are not a substitution for a narrative description.
Location and who was present
To evaluate concurrent billing scenarios, session notes should identify the location of services rendered and all people present for the session. For example, "The beneficiary (name) was in the living room with the behavior technician (name); the BCBA (name) was in the kitchen with the parent without the beneficiary present."
Include a separate line or box for the ABA supervisor, assistant behavior analyst or registered behavior technician (RBT) to record his/her credential level.
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, such as communication, socialization and repetitive behavior, are not sufficient for clinical status.
The narrative summary should indicate the primary areas targeted from the treatment plan, describe the barriers to performance and be representative of the duration 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 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 treatment plan 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 treatment plan and demonstrate the active delivery of ABA techniques for the duration of the session.
ABA techniques such as discrete trial training (DTT), pivotal response treatment (PRT), and 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.
Response to treatment
The narrative description should include of how the beneficiary responded within the current session given the implementation of the treatment plan 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.
Progress towards goals
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 barriers to progress. 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/or any progress towards discharge.
Session notes for 97155 should document what was modified in the program during the session (for example, changes to acquisition charts, progression of objectives/benchmarks, modification to procedures, and behavior intervention plan) and what modeling of the new or modified protocols were demonstrated to the behavior technician and/or parents/caregivers.
Session notes for 97156 should document what ABA principles were covered with the parent/guardian and progress on the parent/guardian goals. The note should include a narrative about what recommendations the ABA supervisor or assistant behavior analysis provided to the parent/guardian on how to improve 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 session note should document what the parent modeled or implemented during the session and the feedback provided. Please note, that clear documentation of who was present during the session (for example, presence or absence of beneficiary) should be included.