CASP CEU Center

Documentation

CASP Organizational Guidelines: Chapter 13

Section: Clinical Operations

Format: online only

Released: January, 31 2022

Chapter Overview:

Quality applied behavior analysis (ABA) services include the use of direct observation, measurement, and functional analysis of the relations between environment and behavior (Council of Autism Service Providers [CASP], 2020). In order to reimburse providers for delivering ABA services in a health care setting, most payers require that the delivery of these services be adequately documented.

Although individual payer requirements vary, behavior analysts who provide ABA for the treatment of autism spectrum disorder (ASD) generally must detail their assessment process, findings, and recommendations in a comprehensive report that provides information about the interventions proposed in the treatment plan. Additionally, the behavior analyst should write a detailed note describing the services provided during each treatment encounter.

These essential activities are part of the process known as documentation—the development of a permanent record of the services that a client has received. This chapter provides guidance regarding best practices in documentation for organizations that bill health care services for individuals with autism. In addition to supporting payment of claims, effective documentation makes it possible for a health care provider to track the client’s treatment progress and communicate critical information to the client’s clinical team and other providers.