Context: This is the full 97155 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 and Suggested Flag | Who is involved in the action item? | Frequency and Type of 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
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
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
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If it was a supervision session, does the note indicate BCBA, Behavior Technician and client in session participants? (overlap of 55 and 53) | Please ensure your session note indicates that you, your technician, and the client were present during the supervision session to display alignment. | Amendment
Flag: Weekly feedback; Amendment needed |
| Weekly
97155 Weekly feedback |
|
Are there at least 3 goals addressed/modified per hour billed? | Please ensure that sufficient protocol modification is documented by targeting goals in accordance with agency protocol (e.g., at least 3 to 4 goals per hour, or at least 2 goals for every additional hour) to support the need for clinical oversight. If fewer goals are addressed during the session, please ensure that there is a clear clinical justification within the documentation. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
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
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Does the POS chosen in the occurrence match the location on the session note? And if there was an overlap between 97153 and 97155 sessions that is NOT Telehealth, do the service locations match?
| There is a mismatch between the timesheet and the POS indicated. Please ensure an amendment is completed to correct the discrepancy. If there is a difference between your note and the technician’s note, please confirm which is accurate. If the error is on the technician's part, please notify us so we can follow up. If the error is on your part, please submit an amendment as soon as possible.
| Amendment by RBT or BCBA
Flags: Staff Follow up; Coordinator Follow up; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
If the BT was listed in the narrative, were they listed as present in session participants and is there an accompanying 97153 note? | Remediation for BCBA: Please ensure consistency in your documentation regarding session participants. If the BT is mentioned in your narrative, they must also be listed as a session participant.
Remediation for RBT: Your supervising BCBA listed you as a session participant; however, there is no corresponding direct care note to reflect that session. Please ensure that a direct care note is created to document the supervised session. If this was listed in error, please notify us. | Amendment
Notify RBT
Notify BCBA
Flags: BCBA Review; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
Was the total 97155 session time for this client shorter than 6 hours this day? | Please ensure the total session time for the client does not exceed 6 hours per day. Billing must be amended when hours exceed the allotted amount. | Notification to prevent future occurrences as well as notify QA staff to fix accordingly.
Amendment and/or corrective claim if billed already.
Flags: Coordinator follow up; Weekly feedback |
| Weekly
97155 Weekly 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; Critical |
| Daily
Instant BCBA 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: Monthly feedback; Weekly feedback |
| Monthly
BCBA Monthly Email |
|
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
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
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 included or documented in the session note. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly 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. Once confirmed, complete an amendment to update the note with the correct information | Amendment
Flag: BCBA Review; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
Does the BT name on the 97153 match the corresponding 97155 session? | Please ensure the BT/RBT listed on the direct care note matches the supervising BT for the corresponding 97155 session; Please complete an amendment to clarify name as necessary. | Amendment
Flag: Weekly feedback |
| Weekly
97155 Weekly
Weekly feedback |
|
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.
| Amendment
Flag: Weekly feedback |
| Weekly
97155 Weekly feedback |
|
Were the dates listed next to the targets/data the same date as the session? | Please ensure the dates listed next to targets and data entries match the actual date of the session; if incorrect, an amendment is required. | Amendment
Flag: Weekly feedback |
| Weekly
97155 Weekly feedback |
|
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
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Was the note devoid of references to activities of daily living skills? | Please avoid referencing activities of daily living (ADLs) in session notes, as unrelated ADL content is not appropriate for ABA services. If ADL-related skills are being targeted, they should be written as ABA goals using behavior-analytic terminology. (You may need to change the goal name if not clinically justified) | Notification to prevent future occurrences.
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Does the “list of programs that were added, or modified” section indicate that additions, modifications, or changes to goals or programs were made at least once per five consecutive sessions? | Please ensure that treatment goals are periodically added, modified, or updated over time to reflect the client’s progress. This service is specifically intended to support routine adjustments and changes to the treatment plan. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If there was a complete overlap between the direct care and supervision session and the BCBA mentioned a barrier of behavior, then is it also mentioned in the corresponding 97153 note? | Remediation for BCBA: Please ensure that your RBT is adequately trained to understand and correctly document what constitutes a barrier. Your note indicates a barrier, while the technician’s note does not. If this discrepancy is clinically justified, no further action is needed. However, if the barrier was incorrectly documented in your note, please complete an amendment. If the omission was on the technician’s part, please notify us so we can follow up accordingly.
Remediation for RBT: Your BCBA documented a barrier in their note, but your session note does not reflect this. If this was an oversight in your documentation, please complete an amendment to correct the record. If you are unsure whether a barrier should have been documented, please reach out to your supervisor for clarification.
| Notification to prevent future occurrences
Flags: Staff follow up; BCBA Review; Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If the times of the direct care and supervision session overlap, does the “response to treatment” section at least partially match the 97153 note? | Please ensure the “response to treatment” section in your supervision note aligns at least partially with the corresponding direct care note when session times overlap, to reflect consistent clinical observations. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If the times of the direct care and supervision sessions completely overlap, does the “summary of observed techniques used by technician during session” match the “techniques used” in the 97153 note but if the times partially overlap, do at least two of the techniques used match? | Please review the “summary of observed techniques used by technician during session” in your note to ensure it matches the “techniques used” section in the corresponding direct care note when sessions. If sessions only partially overlap, at least some techniques should align between the notes. If there is clinical justification, no action may be needed.
| Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If the technician was present during the session, does the note include direction or feedback provided to the technician? | Please update the session note via amendment or addendum to include specific direction or feedback that was provided to the technician during the session, as required when the technician is present. If omitted, an addendum is needed. If it was an error, amend the session note to remove the participant.
| Addendum or Amendment
Flag: Weekly feedback
|
| Weekly
97155 Weekly feedback |
|
Are the BCBA’s indication of which goals (most not all goals – min. 60%) he/she did protocol modification for aligned to the goals mentioned in the corresponding 97153 note? | Please ensure that the goals indicated for protocol modification (at least 60% of goals) align with the goals documented in the corresponding direct care session note. If there is any inaccuracy, please revise and amend it accordingly. Additionally, please provide training to your technician on the importance of accurate and consistent note-taking, as session notes should generally reflect the same information. | Notification to prevent future occurrences
Flag: Weekly feedback |
| Weekly
97155 Weekly feedback |
|
If the times of the direct care and supervision sessions completely overlap, does the “targets addressed” section match the corresponding 97153 for at least 75% of them, or if the times partially overlap, do at least half of the “targets addressed” match? | Please ensure that the targets documented in the corresponding direct care note generally align with those in your note. If there is a clinical reason for any discrepancies, be sure to clearly explain it in the narrative moving forward. Additionally, please provide training to your RBT on the importance of accurate and consistent note-taking, as session notes should generally reflect the same information. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly 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 the session narrative accurately describes any maladaptive behaviors that were selected and addressed. Moving forward, the session narratives should clearly describe the behaviors targeted and align with the data that is tracked.
| Notification to prevent future occurrences
Flag: Monthly feedback
|
| Monthly
BCBA Monthly Email |
|
If the time of the supervision note and direct care note fully overlap, do the participants in the supervision note match the participants in the overlapping direct care note? | Remediation for BCBA: Please ensure that the listed participants in your supervision note align with those documented in the corresponding direct care note. If the discrepancy is due to an error in the technician’s note, please notify us so we can follow up. If the error is in your note, please submit an amendment to correct it.
Remediation for RBT: There is a discrepancy between your direct care note and your BCBA’s supervision note regarding session participants. Please review your note to confirm that the correct participants are listed and submit an amendment to ensure accuracy.
| Amendment
Flag: Staff follow up; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
If the supervision note indicates that the current procedures for a goal were ineffective, is the data on the direct care note not 100% and if the note indicates that the current procedures for a goal were optimally effective, is the data on the direct care note not 0%?
| Please ensure consistency between your evaluation of goal effectiveness and the technician’s data. For example, if session notes indicate 100% accuracy, the procedures should not be marked as ineffective. Likewise, if procedures are marked as effective, the data should not reflect 0% accuracy. Your technician may need to be retrained in taking proper data.
| Notification to prevent future occurrences
Flag: Monthly feedback
|
| Monthly
Feedback for RBT (cc BCBA) |
|
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 |
| Monthly
BCBA Monthly Email |
|
Did the session not occur between 7am and 10pm? | Please ensure sessions are scheduled between 7 a.m. and 10 p.m., as times outside this range are generally not realistic for service delivery and may raise concerns. | Email QA staff for review to make sure clinically justified. Provider notification to prevent future occurrences
Flag: Coordinator Follow up |
| Monthly
BCBA Monthly Email |
|
Are there consecutive barriers to treatment across 5 sessions? | The same barriers to treatment are noted across several consecutive sessions. Please ensure you have a plan to address those barriers in order for the client to progress. | Notification to prevent future occurrences
Flag: BCBA Review |
| Monthly
BCBA Monthly Email |
|
Are behaviors NOT consistently high intensity (at least 5 or more instances) across 5 sessions? | High-intensity behaviors have been consistently observed across multiple consecutive sessions. Please review and update the behavior protocols as needed to ensure effective strategies are in place to reduce these behaviors over time. If there is clinical justification for continuing the current approach, please ensure that it is clearly documented and that the behavior is being closely monitored. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly 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
Flag: Monthly feedback
|
| Monthly |
|
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
Flag: Weekly feedback |
| Weekly
97155 Weekly feedback |
|
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. If billing requirements require you to indicate this location, please clearly note this in the documentation to avoid confusion. | Create amendment (or if there is clinical justification, QA staff should verify)
Flags: Coordinator follow-up; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
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 present, an amendment will be needed to correct the location details. If billing requirements require you to indicate this location, please clearly note this in the documentation to avoid confusion. | Create amendment (or if there is clinical justification, QA staff should verify)
Coordinator follow up; Weekly feedback |
| Weekly
97155 Weekly feedback |
|
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 or daycare. If present, an amendment will be needed to correct the location details. | Amendment
Flag: Weekly feedback |
| 97155 Weekly feedback |
|
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? | For children over age 6 who are legally required to be in school, sessions occurring before that time should not be documented as taking place at home. If inaccurately documented, an amendment is necessary. | Monitor & notify QA staff to see if there is clinical justification.
Flags: Monitor; Coordinator follow up; Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Was the note not created two weeks after the date of service? | Please make sure session notes are created in a timely fashion to ensure compliance and accuracy. | Notification to prevent future occurrences Notify QA team to monitor
Flags: Monitor; Monthly feedback
|
| Monthly
BCBA 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 approved, please disregard). | Notification to prevent future occurrences
Check School Services Approval; Coordinator Follow-up; Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Does a session exceed 3-4 hours? | Please avoid scheduling sessions longer than 3-4 hours (unless you have confirmation from your supervisor for longer), as it is difficult to adequately substantiate session length beyond this timeframe. | Notify QA staff
Provider notification to prevent future occurrences
Flags: Coordinator follow up; Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Is the feedback, including constructive feedback, not a duplicate from the previous session?
| Please ensure that the feedback provided to your Technician includes new, specific information and is not a direct duplicate of feedback from previous sessions. Even if the feedback is similar, it should be individualized and not written identically across sessions.
| Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If BCBA mentions in the narrative that they modified protocols on a behavior or implemented a behavior intervention plan, is there any mention in the narrative that behavior patterns were moderate/severe? | Please ensure alignment within your note and ensure that when the narrative references protocol modifications or behavior intervention plans, at least one behavior pattern is classified as moderate or severe.
| Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Does the first and last name of the technician being supervised match the name on the corresponding 97153 note? | Please verify that the technician’s full name in your supervision note matches exactly the name listed in the corresponding direct care note. An amendment needs to be completed to reflect accurate information.
| Amendment
Flag: Weekly feedback |
| Weekly
97155 Weekly feedback |
|
If a follow up plan was mentioned, is it evident in future sessions that it was applied?
| Please ensure that any follow-up plan mentioned in previous notes is applied in subsequent session notes to ensure alignment.
| Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
If a client begins the session with maladaptive behaviors, is it mentioned in the narrative that behaviors are present? | Please ensure alignment within your note. If the client began the session with maladaptive behaviors, the narrative should also describe how the session progressed in relation to those behaviors.
| Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|
Are the domains the same across 3 consecutive sessions? | Unless it can be clinically justified, please ensure that a variety of goal targets from different domains are addressed to comprehensively support the client’s treatment needs and diagnosis. | Notification to prevent future occurrences
Flag: Monthly feedback |
| Monthly
BCBA Monthly Email |
|