CCS SESSION NOTES GUIDE
IF YOU ARE BILLING FOR REPORT WRITING, YOU MUST STATE THAT
YOU "UPDATED THE TREATMENT PLAN."
PM's CAN ONLY BILL UP TO 2 HOURS FOR TREATMENT PLAN UPDATES.
BCBA MUST BILL AT LEAST 1 HOUR FOR TREATMENT PLAN UPDATES.
Direct session notes requirements:
1. Client Full Name
2. Date of Service
3. Session Start / End Time
4. Total Number of Units
5. Service Location
6. Description of Session
Justify medical necessity
Evidence- based
Least restrictive
Clinically appropriate
Individualized
Remediate symptoms related to ASD
Behaviors require ABA
Goals can be achieved within 6 months
Type of session (supervision, parent training, assessment, re-assessment)
Client appearance
Parent reports (medicine changes, behavior increases, etc.)
Goal names and #s observed/trained
Data collected and/or client/parent’s response to treatment
Synthesize, analyze, and include next steps
7. Practitioner Name and Credential
8. Practitioner Signature
9. Responsible Adult Printed Name
10. Responsible Adult Signature
Supervision example:
The BCBA (Emily Reinheimer) met with the RBT (Cliff Bar), parent (Bubble Gum), and client
(Slim Jim) at previously agreed upon time and location at the client’s home for a regularly
scheduled supervision session from 3:00-4:30PM (6 units). The client appeared happy upon
arrival as evidenced by smiling at the practitioner. There were no medical or safety concerns that
arose. The parent reported that client had a “rough” day at school due to “difficulty sharing” at
recess. The BCBA observed the RBT implement mand training and collected IOA data on goal
#3 mand 3+ words (95%). The BCBA provided training to the RBT on the following antecedent
strategies as outlined in the treatment plan: gain client’s attention before providing instructions
and wait 3-5 seconds before repeating instructions. The RBT demonstrated these skills following
training. The BCBA will provide supervision during the same time and day next week.
Parent training example:
The BCBA (Emily Reinheimer) met with the parent (Bubble Gum) for a parent training session
on behalf of the client (Slim Jim) from 9:00-10:00AM (4 units) on 5/22/23 at the client’s home.
The parent reported that she would like to increase the client’s social skills, specifically
responding to peer’s bids for attention. The parent stated that the client ignores peers at the
playground. The BCBA provided training to the parent on parent goal #2 5:1 ratio. The parent
was able to define the 5:1 ratio as positive interactions/praise vs criticism/ demands. The parent
recorded data on a clip of a parent/child interaction. The BCBA collected IOA. The parent
scored an 80%. The parent has met mastery criteria for this goal. The BCBA will update the
treatment plan to outline this change. During the next parent training session scheduled 06/05/23,
the BCBA will introduce parent goal #3 reinforcement system.
Indirect session notes requirements:
1. Client Full Name
2. Date of Service
3. Session Start / End Time
4. Total Number of Units
5. Service Location
6. Description of Session
Purpose of indirect session – refer to billable activities below
Justify medical necessity
Evidence- based
Least restrictive
Clinically appropriate
Individualized
Remediate symptoms related to ASD
Behaviors require ABA
Goals can be achieved within 6 months
State goal names and #’s analyzed and/or modified
Synthesize, analyze, and include next steps
7. Practitioner Name and Credential
8. Practitioner Signature
Indirect example:
The BCBA (Emily Reinheimer) worked indirectly on behalf of the client (Trader Joe) to update
the treatment plan based on clinical data from 1:00-1:30PM (2 units) on 05/18/2023. The BCBA
updated the following instructional goals: #4 mand 3+ word and #6 take turns. Goal #4 mand 3+
words was updated from “continued” to “met.” The client has met mastery criteria with an
average of 80% independence across the last 5 sessions. #6 take turns was revised to include the
use of a token board following 2 consecutive weeks of below 50% independence. The BCBA has
observed that the client runs away during contrived take #6 turn trials with peers. The BCBA
will update the protocol to include this new reinforcement system and will monitor progress. The
BCBA will provide supervision and update the treatment team on these changes during the next
scheduled supervision session on 06/01/2023.
H0032 (mid-level) billable activities
[ ] Selection of treatment targets in collaboration with family members and other stakeholders
[ ] Development of written protocols for treating and measuring all treatment targets
[ ] Training family members and other caregivers to implement selected aspects of treatment
plan.
[ ] Providing direct clinical coaching and feedback to the Client/family members to promote
treatment progression, generalization and maintenance.
[ ] Collaboration between the treatment team and caregivers resulting in recommendations for
treatment modifications.
[ ] Ongoing, frequent review and analysis of direct observational data on treatment targets.
[ ] Modification of treatment targets and protocols based on data.
[ ] Recommending changes to treatment goals, protocols, and plans based on clinical data.
[ ] Coaching the implementation of a new or modified technique from the treatment plan.
Mid-Level Supervision Requirements All Services must:
Meet Medical Necessity
Be in line with treatment goals on the approved and authorized treatment plan
Be at least 50% face-to-face (direct) with the Client/family
Be overseen by a Qualified Autism Service Provider
The maximum number of units that can be billed for Clinical Report updates and
treatment plan updates each authorization period is 3-hours (across all practitioners and
procedure codes)
H0004 (high-level supervision) billable activities
[ ] Providing direct clinical coaching and feedback to the Client/family members to promote
treatment progression, generalization, and maintenance.
[ ] Collaboration between the treatment team and caregivers resulting in treatment
modifications.
[ ] Adjusting treatment goals, protocols, and plans based on clinical data.
[ ] Transition or discharge reassessments and treatment plan updates (Clinical; not
administrative. Transition & Discharge planning that results in a Transfer or Discharge Report
can be billed if the report is reviewed with the client/family at time of discharge.)
[ ] Crisis intervention.
High-Level Supervision Requirements All Services rendered must:
Meet Medical Necessity
Be in line with treatment goals on the approved and authorized treatment plan
Be provided at least once per month to each Client, as authorized
Be at least 50% face-to-face (direct) with the Client/family
The maximum number of units that can be billed for Clinical Report updates and
treatment plan updates each authorization period is 3-hours (across all practitioners and
procedure codes).