CASP Session Note Templates

Background

The Council of Autism Service Providers (CASP) hosts a number of member-led Special Interest Groups (SIGs) to address topical issues impacting member organizations. SIG work products may include white papers, webinars, position statements, or other resources to support the delivery of sustainable quality autism services. 

The CASP Documentation SIG is led by Rebecca Womack, M.S., BCBA, LBA, and Heather O’Shea, Ph.D., BCBA-D. This group focuses on the challenges of documenting applied behavior analysis (ABA) when delivered as a healthcare service. 

Many providers use templates to facilitate the documentation process. Templates provide prompts that can help to ensure compliance with federal and state laws and regulations, and individual payer requirements. However, the lack of a single set of templates that all payers accept is problematic.

The CASP Documentation SIG sought to develop a session note template for each adaptive behavior CPT Code that:

• Is in alignment with standard medical documentation practices, and
• Reflects generally accepted standards of care for ABA services in accordance with CASP's Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder: Guidance for Healthcare Funders, Regulatory Bodies, Service Providers, and Consumers (CASP, 2024) and AMA CPT code requirements, but
• Is independent of individual payer requirements and state regulations.

The hope is that a CASP-endorsed set of session note templates will result in broad payer adoption of their use and decreased administrative effort for ABA providers.

Important Reminders about CASP's Session Note Templates 

1. The templates are not a substitute for training. 

Each template has a corresponding document that explains how to fill in each section. However, organizations adopting these templates are expected to provide appropriate staff training.

2. The templates may not meet every payer's requirements. 

Organizations are responsible for reviewing their individual payer contracts and ensuring the documentation templates meet payer requirements.  

3. The use of the templates does not guarantee passing audits. 

The templates were designed to align with standard medical documentation practices and in accordance with AMA CPT code requirements. However, the templates must be used correctly. Staff training, monitoring, and internal auditing are necessary to ensure that adequate documentation practices are occurring. 

The Work Process

The CASP Documentation SIG has 275 members representing 105 ABA provider organizations across the United States. Participants included Board Certified Behavior Analysts® representing organizations of all sizes and which accept a wide range of public and private health insurance. 

The CASP Documentation SIG began work on the session note template project in June of 2022. Weekly meetings included input from invited subject matter experts such as health care attorneys, professional medical billing consultants, and representatives from the ABA Coding Coalition.

All SIG participants were strongly encouraged to voice their opinions, especially when there was a lack of agreement. If a unanimous decision could not be reached for a given point (e.g., whether to include a particular field in the template), the decision was made by majority consensus. Most often, the points where agreement was not unanimous are addressed in the guidance section that accompanies each template to allow organizations to choose what is in alignment with their practices.