Official Title of Standard: ANSI/BHCOE-101-2020 Standard for the Documentation of Clinical Records for Applied Behavior Analysis Services

Description: This standard describes appropriate documentation for Applied Behavior Analysis Service delivery and how to provide accurate and supportive medical record documentation.

Status: Approved as an American National Standard.

Excerpt:
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 standard 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.

Payor Adoption: Numerous payors have adopted BHCOE/ANSI 101-2020 to ensure alignment with best practices in documentation in their provider network. If you are a payor who is interested in adopting BHCOE/ANSI 101-2020, please contact info@bhcoe.org.

This document should be referenced as follows:
Behavioral Health Center of Excellence (2020). BHCOE/ANSI 101-2020: Standard for the
Documentation of Clinical Records for Applied Behavior Analysis Services. Los Angeles, CA: Author.

History & Development of the Standards:

Past BHCOE Commission meetings to discuss public commentary were held on the following dates:

• Monday, August 19th, 2019 — 10 AM PST (Registration Closed)
• Monday, September 30th, 2019 — 10 AM PST (Registration Closed)
• Monday, December 9th, 2019 — 11 AM PST (Registration Closed)
• Tuesday, January 7th, 2020 — 10 AM PST (Registration Closed)
• Monday, March 2nd, 2020 — 10AM PST — (Registration Closed)
• Tuesday, March 17th, 2020 — 9 AM PST — CANCELED
• Wednesday, April 22nd, 2020 – 9 AM PST — (Registration Closed)
• Monday, October 5th, 2020 – 10 AM PST – (Registration Closed)

The commission voted to adopt the current draft on June 23, 2020. The results of the commission vote can be found here. The standard underwent additional public commentary from Jun 17 to August 8th, 2020. The commission met again on October 5th to review all comments received. Based on those comments, no substantial changes were made to the standard, and therefore the standard was resubmitted to ANSI for final review.
The standards were approved by ANSI as an American National Standard on November 28, 2020.