Standard for the Documentation of Clinical Records for Applied Behavior Analysis Services

Clear medical record documentation is critical to providing patients with quality care, ensuring timely and accurate payment for services rendered, and mitigating malpractice risks. Clear documentation also helps service providers evaluate and plan patient treatment and maintain continuity of care.

The information in this document constitutes guidance and recommendations to managed care organizations, third-party payors, health insurance issuers, state agencies, ABA organizations, and clinicians on best practices for documentation of Applied Behavior Analysis (ABA) services.

This guidance does not replace payor-specific requirements regarding medical records and interpretation of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes typically found in the Provider Manual and/or Contract unless explicitly stated by the payor. Deviation from this format or its requirements should not be used to deny or limit coverage of Applied Behavior Analysis services.