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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

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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

Appreciation 2

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.

4

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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What does that mean?

Be prepared for an audit

Any where, any time, and any place

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Audits – Any where,

Any time, Any Place

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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:

[email protected]

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