Documentation and Auditing

Practical Safeguards for Clinical Success

Original Air Date: January 11, 2021 (as part of the CASP 2021 UnCONVENTIONal Conference)

CEU offered: 1.0 Ethics CEU

Short Title:  Documentation and Auditing

Webinar Duration: 1 hour

CE Instructors:

  • Rebecca Womack, BCBA


Abstract: 

Organizations that provide applied behavior analytic (ABA) services to people with autism spectrum disorder (ASD) have an ethical, legal, and contractual obligation to document their work. It is imperative that the processes for equipping behavior analysts with the tools to produce high-quality session notes also enables them to discuss the medically necessary treatment provided. Organizations must have a clear understanding of what information is required by each funding source, and how to capture the elements of treatment provided that pertain to the billed CPT® code. They must also be able to evaluate their session notes on a regular basis to ascertain the quality of documentation in order to mitigate risks in the event of an external audit. By using carefully crafted auditing tools and systematic auditing processes, organizations can efficiently evaluate their session notes. Statistical sampling enables organizations to make determinations about their auditing results supported by arithmetic confidence levels. This allows organizations to then strategically plan for how to improve their documentation as needed. This session will discuss the essential elements of documenting medically necessary treatment and recommend systems and tools for effective auditing processes. 

Instructor(s)

Rebecca Womack, MS, BCBA, LBA

Rebecca has been privileged to serve adults and children using applied behavior analysis (ABA) in settings such as facility-based care, group homes, day centers, clinics, and family homes both across the United States and overseas. In addition to her clinical experience, Rebecca is passionate about ABA service delivery aligning with generally accepted standards of care. With an expertise in applying health care documentation requirements and systems of compliance, she recently was the author of a chapter on documentation guidelines for ABA services. Rebecca is co-chair of the Documentation Special Interest Group (SIG) for the Council of Autism Service Providers (CASP), a co-leader for the AI/ML Workgroup, an appointed Subject Matter Expert for the Association of Professional Behavior Analysts, and a Member of the Board of Directors for the Behavior Analyst Certification Board (BACB). Rebecca also has extensive experience with public policy work. Not only is she an experienced presenter at national conferences, she has also won national awards for her role as an advocate and work to support ABA organizations in delivering quality services. Rebecca formed RAW Consulting Solutions as a way to provide education and consultation services to ABA organizations, professionals, and providers of ABA services. Whatever the role, her ultimate goal is to make a significant impact through effective and efficient services utilizing the science of behavior analysis.