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Aligning TRICARE Autism Care Demonstration and BACB Compliance Code Documentation Requirements
REBECCA WOMACK , MS, BCBA, LBA – BEHAVIOR ANALYSIS ADVOCACY NETWORK
1
Disclaimers:
Content shared in this presentation summarizes the
presenter’s understanding of information presented by
Defense Health Agency personnel in a workshop at the
Association of Professional Behavior Analysts convention,
April 19 in St. Louis, MO as well as information about the Autism Care Demonstration (ACD) in the current TRICARE
Operations Manual (TOM). Providers are urged to check
all information with their points of contact and to use
their best judgement when determining how to proceed.
BAAN is not affiliated with the Department of Defense or
the U.S. government.
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Agenda
Results of audit of North Region, March 2018
TOM information on documentation requirements
Application
Questions
Please hold all questions until the end of the presentation.
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Office of Inspector General
Audit Report5
To view report:
1)http://www.dodig.mil/reports.html/
2) Keyword: TRICARE
3) Report type: Audit
4) Published March 14, 2018
5) Bottom of page a link to full report
OIG
Report
Improper Payments
Definition: any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements
Session Note
Definition: documentation completed by provider detailing session content and is a part of the patient medical record
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OIG Report
Audit covered 2015 and 2016, North Region
66% of documentation reviewed was found to be poor/insufficient
Statistically projected $81.2 million of the total $120.1 million in payments to ABA providers were improper
Audit consisted of
Off sight document review
Two unannounced visits to ABA companies
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OIG Audit Criteria
Reviewed various aspects of provider responsibilities for
documentation
Looked for required components
Date and time
Length of the session
Session content
The number of units billed equals the time noted in the
session notes; and
Absence of concurrent billing
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OIG Report – Common Findings
Documentation for claims was found to be insufficient when:
Did not provide the supporting documentation
Did not include the ABA provider or beneficiary name
Did not provide documentation to support the length of the
beneficiary’s time receiving covered ABA services
Did not summarize the covered ABA services delivered during
the session
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Example
North contractor paid
$125 for 2.5 hours of ABA services provided by a BT
$250 for 2 hours provided by a BCBA
BT Session note did not summarize the covered ABA services
No session note from the BCBA
ABA Company may have concurrently billed for BT and BCBA;
no allowed
Treatment plan did not cover time frame (out of date)
Treatment plan was not individualized
Included one academic goal
Determination: Improper payment was issued
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OIG Recommendations
Main issue
Insufficient documentation to warrant payment
DHA unable to justify reimbursement of ABA claims based on documentation
Revise policy to require annual
comprehensive medical reviews ABA
providers’ claims
Audits should continue to compare
session note content with provider claims
Pursue recouping any overpayments due
to no or poor documentation from ABA
providers from sample
2015
DHA
Agreed with recommendations
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Ethical Considerations
1.04(c) Behavior analysts follow through on obligations,
and contractual and professional commitments with high quality work and refrain from making professional
commitments they cannot keep.
1.054 (b) When behavior analysts provide behavior-
analytic services, they use language that is fully
understandable to the recipient of those services while
remaining conceptually systematic with the profession of behavior analysis.
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TOM Requirements -17.2
Date and time of session
Length of therapy session
A legible name of the rendering provider,
including provider type/level
Signature of the rendering provider
A notation of the patient’s current clinical status
evidenced by the patient’s signs and symptoms
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TOM Requirements -17.2
A statement summarizing the techniques
attempted during the session
Description of the response to treatment
Outcome of the treatment
Response to significant others
A statement summarizing the patient’s degree of
progress towards the treatment goals
Progress notes should intermittently (at least
monthly) include reference to progress regarding
the periodic ABA program review established
early on in the patient’s treatment.
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What is NOT in the note
Therapist’s speculations, personal feelings or judgments about the patient
Any information, events, experiences, or descriptions not relevant to the patient’s functional status and treatment plan
Identifying information about persons who are not directly involved in the patient’s treatment
Clinical judgments, conclusions, impressions, or diagnoses that cannot be justified by accepted methods of assessment and treatment, therapist scope of practice, and other acceptable forms of clinical evidence
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Caveats
Focus on session note documentation
Content is a result of interpretation of information
shared by DHA
Meetings
Presentation
TOM
Follow up with contractors
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Common Challenge for
Providers
A notation of the patient’s current clinical status
evidenced by the patient’s signs and symptoms(17.2)
Clinical status – topography
Describe the topography of the beneficiary’s
behaviors
Changes since past session or throughout
authorization period
Responded to therapy (well/poorly) as evidenced
by…
Want to know what the beneficiary is doing, where
s/he is in the course of his/her treatment
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When Services Are
Provided
Session note is required
What is different per note is the type of activity performed
Filled out at the end of session
Must contain all required elements
Must be legible
CPT codes:
0360T/0361T 0368T/0369T
0364T/0365T 0370T
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Example – Session details
All information included
Must be legible
Make sure all parts of note have been filled out
Encourage RBTs, BCBAs to always double check session
notes
RBT/BCBA signature required
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Greg SmithLacey Johnson - RBT
5/18/2018 3:00 pm 6:00 pm 3 hours
Example – Session content
Adaptive Behavior Treatment 0364T/0365T
Information pertains to what was going on with direct
care
Sara’s aggression occurred 5 times during the session.
Graphed data from the 3 most recent sessions indicates
that the frequency of aggression is decreasing. Sara hasmastered 7 out of 10 targets related to requesting. Sara has
2 out of 25 targets related to labeling.
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Degree of progress Clinical status
Sign/symptom
Degree of progress
Example - Session content
Supervisor note (CPT 0360T/0361T)
Information reflects supervisor’s observations of BT
RBT implemented DTT and incidental teaching targeting fine motor skills, receptive and expressive language, and
decreasing patterns of rigid behavior. BCBA modeled least-
to-most prompting for RBT and provided feedback on how to improve implementation of those procedures
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Intervention used
Interventions used
CPT Documentation
Requirements 0368T/0369T Adaptive Behavior Treatment by
Protocol Modification
Must include:
All required elements
Who was present
What was done (program revision, assessment, type
of change made)
Beneficiary’s response
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CPT Documentation
Requirements
0370T Family Adaptive Behavior Treatment Guidance
Must include:
All required elements
Parent’s participation – Topography
Description of what took place – Training on interventions?
What targets?
Their response – Provide data reflecting skills they’re
acquiring; any challenges
Anomalies – Divorce? Parent being deployed?
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Session Note
Recommendations
Hold trainings on how to write succinct narratives
Conduct internal quality reviews
State how the beneficiary is doing with their
treatment
Make sure all treatment plans are individualized
If session notes include graphs, use axis labels and
a title
Make sure treatment plan goals match up with session content
Do not initial session notes; sign full name
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Session notes - summary
If you are providing a service, it must be documented
The content of each service should be reflected in note
Services delivered must align with what is approved
When in doubt, ask Humana/Health Net Federal Services
If no response, email DHA
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Questions?
Your additional questions, comments, or suggestions
are appreciated!
Connect with me:
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