Overview
Applied behavior analysis (ABA) providers must maintain progress notes (also referred to as narrative summaries or session notes) that relate to the goals and objectives outlined in TRICARE beneficiary treatment plans. Progress notes must support the respective ABA claims billed. ABA providers do not need to submit progress notes with claims; however, Health Net Federal Services, LLC (HNFS) may request progress notes during an audit.
HNFS offers a printable Medical Documentation Requirements resource guide to support the development of compliant progress notes.
Required Progress Notes Elements
This list is not all-inclusive. Please review TRICARE Operations Manual (TOM), Chapter 18, Section 4 and TRICARE Policy Manual (TPM), Chapter 1, Section 5.1 for complete details.
- Beneficiary’s full name
- Date, time (start/end time), length of session
- Location of rendered services
- Names of session participants
- Rendering provider’s name and license or certification
- Dated signature (Important: The dated signature requirement refers to the date the progress note was signed and may differ from the date listed for the session date requirement. Dates must be entered for both requirements.)
- Full name of authorized ABA supervisor (if different than the rendering provider)
- Beneficiary’s current clinical status (as observed at the beginning of each session)
- Narrative summaries of session content to include details per Current Procedural Terminology (CPT®) code
- ABA techniques attempted, response to treatment, and progress toward treatment goals
In addition to containing all elements listed above, progress note narrative summaries should reflect the active ABA services delivery for the full duration of the session. For example, a progress note for a six-hour session would require greater content than a two-hour session. Progress notes for CPT code 97156 should document the services rendered to the parent/caregiver for the duration of the session and progress toward parent/caregiver goals.
ABA providers do not have to document all programs implemented within a session; however, progress notes should support and justify the claim and clearly demonstrate the ABA services provided.
Element Details
ABA providers are encouraged to design templates for their use to ensure progress notes contain all required elements and meet Autism Care Demonstration (ACD) criteria. HNFS does not provide or create templates for this purpose.
Beneficiary's name
The beneficiary’s full name is required. Beneficiary initials or numerical identifiers do not meet the requirement.
Date/time/length of session
The date refers to the date the session occurred. (Important: The dated signature requirement refers to the date the progress note was signed and may differ from the date listed for the session date requirement. Dates must be entered for both requirements. Also refer to the "Required Progress Notes Elements" section above.) The start and end times of each session must be documented exactly as they occurred, including the duration of each session. While military time format is required on ABA claims submissions, providers do not need to use military time when documenting session times in progress notes. If using standard (civilian) time format, be sure to include “a.m.” or “p.m.”
Service location
The place of service (home, clinic/center, daycare [non-preschool], school, community, telemedicine) must be documented. GPS coordinates or addresses will not meet this requirement. Visit our ABA Service Settings/Locations page for requirements and exclusions related to service locations.
For concurrent billing scenarios at the same service location, the location of the services rendered and participants in the session must be documented for each service. 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 (name), without the beneficiary present."
Session participants
A session participant's name and relationship to the beneficiary must be documented. Include those who actively participated in the session. Do not include names of other beneficiaries.
Note: Documenting the name of the rendering provider to fulfill the rendering provider requirement and the name of the beneficiary to fulfill the beneficiary full name requirement alone will not satisfy the session participant name/relationship requirement. Names of all active session participants and their relationships to the beneficiary must be documented regardless of whether they have been mentioned in other areas of the progress note.
Provider details
The progress notes must include the full name and license or certification of the rendering ABA supervisor, assistant behavior analyst or behavior technician (BT), with a dated signature. (Important: The dated signature requirement refers to the date the progress note was signed and may differ from the date listed for the session date requirement. Dates must be entered for both requirements. Also refer to the "Required Progress Notes Elements" section above.)
Name of authorized applied behavior analysis supervisor
If the ABA supervisor is not the rendering provider, notes also must include the ABA supervisor's full name. The ABA supervisor’s full name should be documented even if the ABA supervisor was not present during the session. This requirement is separate from the requirement to document session participants.
Clinical status
Documentation of clinical status must be on progress notes for services where the beneficiary is present, to include treatment modification and parent/caregiver training sessions.
The clinical status refers to specific, objectively observed behavior displayed by the beneficiary upon arrival and/or at the beginning of each session. The status also may include a report of setting events.
Clinical status may impact the beneficiary's session or readiness for learning at the time. For example, the beneficiary's status at the start of the session may influence the application of ABA principles throughout the session, including the frequency and type of preference assessments, behavior momentum, type of teaching techniques used, modifications to the environment, and possible impact on performance.
Note: Listing the diagnostic criteria for autism spectrum disorder (ASD) (for example, communication, socialization and repetitive behavior) or using check boxes to indicate "stable" or "unstable," will not be sufficient to meet this requirement.
Narrative of session content
The content summary should clearly describe the services provided during the session and include examples that support the CPT code. This narrative should be objective, specific and individualized to the session. Refer to the "Descriptions by Current Procedural Terminology Code" section of this page for details on documenting session content by CPT code rendered.
Descriptions by Current Procedural Terminology code
- CPT code 97151: Document what activity, measures, observations were administered during the assessment.
- CPT code 97153: Include the domains targeted in the treatment plan, examples of targets addressed, and highlight progress and barriers on individual targets as appropriate. Note: List of targets or goals with performance data (for example, 80%), do not meet this requirement.
- CPT code 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. If no modifications are needed, the documentation should clearly support how the provider made this determination.
- CPT code 97156: Document ABA principles covered with the parent/caregiver and progress toward parent/caregiver goals. The note should describe recommendations the ABA supervisor or assistant behavior analyst provided to the parent/caregiver 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/caregiver training, the note should document what was modeled for the parent/caregiver or what the parent/caregiver implemented during the session and the feedback provided.
- CPT code 97157: Describe session content, including what ABA principles were covered in the group parent/caregiver training, the specific skill acquisition and behavior reduction techniques that were reviewed, what was modeled, and the feedback provided (if relevant). A common summary may be used.
- CPT code 97158: Describe what social deficit areas, skill acquisition targets and problem behaviors were addressed in the group session. A common summary may be used.
- CPT codes 99366 and 99368: Report participants’ documentation of their role in the medical conference, contributed information and subsequent treatment recommendations.
Narrative of applied behavior analysis techniques
ABA techniques such as discrete trial training (DTT), pivotal response treatment (PRT), chaining and prompting can be listed or marked in a check box. Progress notes should highlight changes in teaching techniques within the content of the session.
Narrative of response to treatment and outcome of treatment/response to significant others
Notes for CPT code 97153 must include the individual patient’s response to treatment in the current session (even if a group session), given the implementation of the treatment plan goals. Summarize how the beneficiary performed on targeted goals with a focus on areas of strong performance and provide an explanation of barriers to performance. Highlight individual targets that met mastery criteria and any instances of the patient generalizing a targeted skill to other people (if relevant). Individual data points, performance data (for example, 80%), tally marks, circled responses (for example, positive, negative, present or not present) do not meet this requirement. BTs may indicate the progress the beneficiary is making within the current session or as compared to the prior session.
Narrative of progress toward goals
Progress notes for CPT codes 97153 and 97155 completed by an ABA supervisor or assistant behavior analyst should report on progress over time on the goal to date and identify barriers to the anticipated acquisition rate. The progress note should include any goals that are met and/or any progress toward discharge.
Progress notes for CPT code 97156 must document progress toward parent/caregiver goals.
When CPT code 97153 is rendered by BTs, 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 barriers to progress for the ABA supervisor.
Measurable, specific and individualized language should be used to document progress.
Common Mistakes
- Missing required element. Elements commonly missed include:
- Location of rendered services
- Session participants
- Rendering provider’s license or certification
- Rendering provider’s dated signature (See the "Required Progress Notes Elements" section above for details.)
- Full name of authorized ABA supervisor
- Clinical status (includes CPT codes 97155 and 97156 [if the beneficiary is present])
- Progress toward goals for CPT code 97155
- Progress toward parent/caregiver goals for CPT code 97156
- Content summary does not support the CPT code on the claim
- Content summary does not provide details and examples of the service that was provided
- Content summary does not support the services performed for the duration of the session
- Progress notes for CPT code 97155 do not support a change or addition to the protocol, or explain why no change is needed
- Billing for excluded areas (academics, activities of daily living, vocational, non-core ASD symptoms, supervision or training of BTs); refer to our Exclusions page and TOM, Chapter 18, Section 4 for more information
- Billing for team meetings. Team meetings, including CPT code 97155 billed for meetings with school personnel are not reimbursable under the ACD. This includes attendance at Individualized Education Program meetings. This applies to all beneficiaries under the ACD, whether or not they are approved to receive services in the school setting. (Also refer to our Exclusions page and TOM, Chapter 18, Section 4 for more information).
- Billing for supervision. The oversight and supervision of BTs and assistant behavior analysts is required as clinically appropriate and in accordance with the Behavior Analyst Certification Board® (BACB®) guidelines and ethics but are not billable under the ACD. (Also refer to our Exclusions page and TOM, Chapter 18, Section 4 for more information).
