Context: This is the full 97153 question set for the Advanced ABA workflow. Please refer here for instructions and additional information.
Note: Remediations recommended here are general recommendations and should be adjusted as needed to align with your organization’s operational procedures.
Question | Remediation | Corrective Action + Suggested Flag | Who is involved in the action item? | Frequency of outreach and email schedule |
Is the session narrative and session data NOT copy / pasted from a previous session? | Please ensure that each session narrative is original and specific to the current session, avoiding copy-pasting from previous notes. | Notification to prevent future occurrences
Flags: Staff follow up; Monthly feedback | RBT | Monthly RBT Feedback |
Is the session data field NOT copy / pasted from a previous session? | Please make sure the session data is unique and accurately reflects the current session, avoiding any copy-pasting from previous notes. | Notification to prevent future occurrences
Flags: Staff follow up; Monthly feedback | RBT | Monthly RBT Feedback |
Are there at least 3-4 goals worked on per hour billed? (2 if barriers listed) | Please ensure that there is adequate clinical substance by targeting sufficient goals (at least 3-4 goals per hour). Less (2) goals may be targeted if barriers were present. | Notification to prevent future occurrences
Flag: Monthly feedback | RBT | Monthly RBT Feedback |
Does the session narrative only mention content relevant to ABA Therapy? | Please ensure the session narrative focuses solely on ABA therapy content and excludes unrelated information. | Notification to prevent future occurrences
Flags: Staff follow up; Monthly feedback | RBT
| Monthly RBT Feedback |
Does the POS chosen in the occurrence match the location on the session note? | Please confirm and verify that the Place of Service (POS) selected matches the actual location documented in the session note; there is a discrepancy, and an amendment must be submitted to correct the record. | Amendment
Flags: Staff follow up; Coordinator follow up; Monthly feedback |
| Monthly RBT Feedback |
If the BCBA was listed in the narrative, were they listed as present in session participants and is there an accompanying 97155 note? | If the BCBA is mentioned as present in the narrative, please ensure they are also listed in the session participants. If the BCBA was omitted from participants, complete an amendment. | Amendment
Flags: Staff follow up; Monthly feedback |
| Monthly RBT Feedback |
Was the total 97153 session time for this client shorter than 8 hours this day (97153 cumulative) | Please ensure the total direct care session time for the client does not exceed the allotted number of hours per day. Please consult your supervisor if you have any questions. If the error is confirmed, create an amendment to adjust billing accordingly. | Notification to prevent future occurrences as well as notify QA staff to fix accordingly.
Flags: Coordinator follow up; Monthly feedback |
| Monthly RBT Feedback |
Was the session not double billed with any other sessions? | Please confirm that the session was not double billed with any other sessions. If double billing occurred, please notify the office/supervisor immediately as it must be remediated as soon as possible.
| Quick action needed – notify QA staff & Amendment/Corrective Claim needed
Flags: Coordinator follow up (only if double billing occurred); Critical |
| Daily (only if double billing occurred)
Instant RBT email |
Was the note signed within 24 - 48 hours of the end of the session? | Please ensure notes are signed within 24 to 48 hours after the session ends to maintain timely and compliant documentation. | Notification to prevent future occurrences
Flags: Staff follow up; Monthly feedback |
| Monthly RBT Feedback |
Was the note not signed before 15 minutes of the end of the session? | Please ensure your notes are signed at the end of the completed session in order to ensure accurate and complete documentation.
| Notification to prevent future occurrences
Flags: Monthly feedback
| RBT | Monthly RBT Feedback |
Was the session note devoid of references to nap/sleep? | Please remember that nap and sleep time are not permitted during ABA services and should not be documented in the session note. | Notification to prevent future occurrences
Flags: BCBA Review; Monthly feedback
|
| Monthly RBT Email
BCBA Review Email |
If a BIP was implemented, were behaviors not listed as no behaviors present?
| If a BIP was implemented, please ensure behaviors are accurately reported and not marked as “no behaviors present.” If there was no BIP implemented, make sure behaviors are not listed as severe or high. | Amendment
Flag: Monthly feedback | RBT | Monthly RBT Email |
Does the supervisor name on the 97155 match the corresponding 97153 session? | Please ensure the correct supervisor is listed on your note; if there is a mistake, complete an amendment. | Flag: Weekly feedback | RBT | Weekly RBT Email |
Do the note’s start time, end time, and date of service align with the timesheet? | Please ensure the note’s start time, end time, and date of service align with the timesheet; discrepancies must be corrected with an amendment once confirmed with the supervisor.
| Amendment
Flag: Weekly feedback |
| Weekly RBT Email
BCBA Follow-Up |
Were the dates listed next to the targets/data the same date as the session? | Please ensure that the accurate dates of service are populated next to the targets and data entries. If incorrect, complete a requirement. | Amendment
Flag: Weekly feedback | RBT | Weekly RBT Email |
Was the note devoid of references to doctor, OT, PT, dentist etc.? | Please ensure the session note does not include references to doctors, OT, PT, dentists, or other non-ABA services, as they are not relevant to ABA services. | Notification to prevent future occurrences
Flags: BCBA Review; Monthly feedback |
| Monthly RBT Email
BCBA Review Email |
Was the note devoid of references to activities of daily living skills? | Your RBT referred to ADL skills in their session note. Please avoid referencing activities of daily living (ADLs) in targets/goals, as unrelated ADL content may not be appropriate for ABA services. If ADL-related skills are being targeted, they should be written as ABA goals using behavior-analytic terminology. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly RBT Email
BCBA Review Email |
If peers, siblings or other participants are listed as present in the session, does it make mention of those participants in the session narrative/goals? | If peers, siblings, or other participants are listed as present, please ensure the session narrative and/or goals reflect their involvement to maintain consistency and clinical relevance. | Notification to prevent future occurrences
Flag: Monthly feedback | RBT | Monthly RBT Email |
If the supervisor was listed as present, was there a corresponding 97155 note? | Remediation for BCBA: Your RBT mentioned you as a participant in their note, but there is no corresponding supervision note accounted for. Please ensure a corresponding supervision note is submitted to accurately reflect supervision services. If this is the RBT’s error and you were not present, notify us so we can have the RBT complete the remediation.
Remediation for RBT: You mentioned your supervisor as a participant in your direct care session; however, they confirmed they were not present. Please complete an amendment to reflect accurate participant information.
| Notify QA staff
Notify BCBA or RBT that note needs to be created
Flag: Coordinator follow up; Monthly feedback |
| RBT Monthly Email
OR
BCBA Review Email |
If the goals are all 100%, does the summary of progress not mention client regression? And if the goals are all 0%, does the summary of progress not say client mastered targets/making progress? | Please ensure the summary of progress aligns with the reported data. e.g. if goals are at 100%, avoid mentioning client regression, and if goals are at 0%, avoid stating the client is mastering targets or making progress. | Notification to prevent future occurrences
Flag: Staff follow up; Monthly feedback | RBT | Monthly RBT email |
If a client’s participation was described as not participatory, were there details to follow up on it in the summary? | If the client’s participation is described as not participatory, please include detailed follow-up information in the summary to explain and address this observation. | Notification to prevent future occurrences
Flag: Monthly feedback
| RBT | Monthly RBT email
Low severity |
If the BCBA was marked present, were they listed in the narrative? | If the BCBA was marked present, please ensure they are also mentioned in the session narrative for consistency. | Notification to prevent future occurrences
Flag: Monthly feedback
| RBT | RBT Monthly Email |
If behaviors were listed as severe, was a BIP used (or if client note doesn’t list severity, are there at least 5 instances of behavior)? | Remediation for RBT: If severe behaviors are present, please ensure a Behavior Intervention Plan (BIP) is implemented. Ask your supervisor for more clinical direction if needed.
Remediation for BCBA: Your RBT noted the presence of severe behaviors; however, there is no documentation indicating that a Behavior Intervention Plan (BIP) was implemented. Please follow up with your RBT to provide retraining on proper BIP implementation. | Notification to prevent future occurrences
Notify RBT
Notify BCBA
Flag: Monthly feedback
|
| RBT Monthly Email
BCBA Review Email |
If there are multiple sessions per day, is the data included different from the other session notes? | When multiple sessions occur in a day, please ensure that the data recorded for each session is individualized and accurately reflects that specific session. If the same data was erroneously pulled in twice, create an amendment to pull in only accurate information. | Notification to prevent future occurrences or amendment if wrong session pulled
Flag: Monthly feedback
| RBT | RBT Monthly Email |
Is the purpose of the session not “RBT/BT worked on pairing self with reinforcers” for no more than 5 consecutive sessions? | Remediation for RBT: Pairing should not be worked on for several consecutive sessions; if it is, please be in touch with your supervisor to make sure it is clinically necessary.
Remediation for BCBA: Your RBT has been working on pairing goals for several consecutive sessions. Please monitor closely as this may indicate a lack of progress and the need for intervention. | Notification to prevent future occurrences
Notify QA staff, BCBA, and RBT
Flags: BCBA review; Staff follow up; Coordinator follow up; Monthly feedback |
| RBT Monthly Email
BCBA Review Needed |
Were all the goals not 0% or 100% across 5 consecutive sessions? | Remediation for RBT: Please ensure client progress varies across sessions; if all goals remain at 0% or 100% across several sessions, it can be a flag and you may need to reassess with your BCBA.
Remediation for BCBA: Please ensure goal progress varies across sessions; if all goals remain at 0% or 100% for several consecutive sessions, it may indicate a need to reassess or adjust the treatment plan. It may also indicate that the RBT isn’t taking accurate data collection and may need retraining.
| Notification to prevent future occurrences.
Notify RBT
Notify BCBA so they can make appropriate adjustments to ensure progress.
Flag: Monthly feedback |
| Monthly RBT Email
BCBA Review Email |
Did the session not occur between 7am and 10pm? | Please ensure sessions are scheduled at appropriate times, as irregular times for service delivery may raise concerns. If it can be clinically rationalized, include that in the note. Contact your supervisor with any questions.
| Email QA staff for review to make sure clinically justified. Provider notification to prevent future occurrences
Flags: Coordinator follow up; Monthly feedback |
| Monthly RBT Email
|
Are there no consecutive barriers to treatment across 5 sessions? | Remediation for RBT: If the same barriers to treatment are noted across several consecutive sessions, please notify your BCBA so they can implement program adjustments to address the challenges.
Remediation for BCBA: Your RBT has noted the same barriers to treatment across several consecutive sessions, please evaluate the need for program adjustments to address the challenges. | Notification to prevent future occurrences
Flags: BCBA Review; Monthly feedback |
| Monthly RBT Email
BCBA Review Needed |
Are behaviors NOT consistently high intensity (at least 5 or more instances) across 5 sessions? | If high-intensity behaviors (5 or more instances) are consistently observed across several sessions, please contact your BCBA to assess if interventions need to be adjusted. | Notification to prevent future occurrences
Flags: Monthly feedback |
| Monthly RBT Email
BCBA Review Email |
Is the session narrative sufficiently detailed given the length of the session? (2 sentences per hour) | Please ensure the session narrative includes sufficient detail, at least two sentences per hour, to substantiate the length and content of the session.
| Notification to prevent future occurrences
Flags: Monthly feedback
| RBT | Monthly RBT Email |
If the service location was not telehealth, were telehealth platforms not mentioned? | If the service location was not telehealth, please ensure telehealth platforms are not mentioned in the session note. If inaccurate information was included, complete an amendment to correct the record. | Amendment
Flags: Monthly feedback
| RBT | Monthly RBT Email |
If the location is school/daycare, were there no references to home? | If the session took place at school or daycare, please ensure there are no references to the home setting in the note. If there’s an error, an amendment is required to ensure accurate reporting. | Amendment (or if there is clinical justification, QA staff should verify)
Flags: Staff follow up; Coordinator follow up; Monthly feedback |
| Monthly RBT Email |
If the location is home, community or office, were there no references to school or daycare? | If the session occurred in the home, community, or office, please ensure there are no references to school or daycare; if inaccurate information included, complete an amendment to correct the location details. If there is an exception and you have been given permission to reference school or daycare, then you may disregard this notification. | Amendment (or if there is clinical justification, QA staff should verify)
Flags: Staff follow up; Coordinator follow up; Monthly feedback |
| Monthly RBT Email
If there is an exception, this notification can be disregarded |
If the session starts after 3:30/4:30pm, is the location listed not school? | If the session occurred after school time, please ensure there are no references to school. If present, an amendment should be completed to correct the location details. | Amendment
Flag: Weekly feedback | RBT | Weekly RBT Email |
If a child is over the age of 6, and legally required to be in school until 3:30pm, are sessions before 3:30 not listed as home? | Remediation for BCBA: For children who are legally required to be in school, sessions during school time is a flag unless it is clinically necessary. Your RBT has indicated “home” in their session note, please review to ensure there is appropriate rationale and justification. If there isn’t, notify us so we can let the RBT know an amendment is necessary.
Remediation for RBT: Your session note indicates “home” during your client’s typical school hours. Please review your note and create an addendum to reflect the proper location.
| Monitor & notify QA staff to see if clinical justification
Flags: Coordinator follow up; BCBA Review; Weekly feedback |
| BCBA Follow-Up
RBT Weekly Email |
Do maladaptive behaviors mentioned in the session narrative match the maladaptive behavior selected (either found in behavior tracking or behavior listed)? | Please ensure that any maladaptive behaviors mentioned in the session narrative align with the behaviors selected in tracking or listed in the note. If data was inaccurately mentioned in the details, please complete an amendment to maintain accuracy and alignment. | Amendment or notification to prevent future occurrences
Flag: Weekly feedback | RBT | RBT Weekly Email |
Was the note cosigned by the BCBA? | Remediation for BCBA: Please ensure that your RBT’s note is cosigned to meet documentation requirements. | Updated signature required & notify BCBA
Flag: BCBA Co-signature; Monthly feedback | BCBA and RBT | BCBA Review Email (BCBA Cosignature)
Monthly RBT Email |
Was the note not created two weeks after the date of service? | Please make sure session notes are created in a timely fashion, ideally no more than 2 weeks of the date of service, to ensure compliance and accuracy. | Notification to prevent future occurrences
Flag: Monthly feedback
| RBT and QA staff | RBT Monthly Email |
Were reinforcements & ABA procedures used not left blank or n/a? | Please ensure the sections on reinforcements and ABA procedures are fully completed and not left blank or marked “N/A,” as this information is essential to demonstrate proper delivery of ABA services. If you have accurate records that indicate the above details were implemented, create an addendum. | Notify RBT
Addendum
Flag: Monthly feedback | RBT | RBT Monthly Email |
Are the session narrative and goals devoid of references to teacher/class/classroom? | Please ensure the session narrative and goals do not include references to teacher, class, or classroom, as these are not relevant to ABA therapy and not allowed by most payors (if school is not an accepted POS) | Notification to prevent future occurrences
Flag: Monthly feedback | RBT | Monthly RBT Email |
If a barrier to treatment is listed as a behavior, is the behavior severity listed as either moderate or severe (or if client note doesn’t list severity, are there at least 5 instances of behavior in data)? | If a behavior is listed as a barrier to treatment, please ensure its severity is documented as moderate or severe to ensure alignment of information. | Notification to prevent future occurrences
Flag: Monthly feedback | RBT | Monthly RBT Email |
Does a session exceed 3-4 hours? | Sessions longer than 3-4 hours must have sufficient information to substantiate services. | Notify QA staff to monitor
Provider notification to prevent future occurrences
Flags: Monitor; Monthly feedback
| QA team and RBT | Monthly RBT Email |
If client assent is not given, is the way it was addressed included?
| In future notes, please delineate if assent was not given and what steps were taken.
| Notification to prevent future occurrences
Flag: Monthly feedback | RBT | Monthly RBT Email |