ABA session notes that hold up in an audit: what Florida Medicaid requires

Florida Medicaid’s coverage policy first sets the standard: all documentation must reflect the individual assessments, needs and interventions of the recipient¹. Section 6.2.4 then says session notes must be signed and dated by the rendering practitioner and include seven items¹:

1. Date, time, location and duration of services
2. Maladaptive behaviors observed during the session
3. The replacement or compensatory skills targeted during the session
4. A description of the recipient's response to the treatment interventions
5. Protocol modification, changes to goals or objectives, and/or therapist directions provided during the session, if included
6. An explanation if the recipient's parent or guardian is not present during the service
7. Participants, including observers, teachers, parents, caregivers or other health care providers if present

In group services, providers must also keep the other participants’ information confidential¹. If a parent’s participation is not possible, the plan and the notes must document the reasons, and the documentation should explain the possible impact and how it is being mitigated¹.

The policy refers general documentation questions to Florida Medicaid’s recordkeeping requirements¹. The general rule on the subject, 59G-1.054, applies to providers rendering Florida Medicaid services². It requires you to sign and date each medical record within two business days from the date and time of service, or authenticate it by signature, written initials or computer entry. Electronic signatures are permitted as defined in chapter 668, part I, of the Florida Statutes².

Records must show the medical necessity and extent of the services, be accessible, legible and comprehensible, and be kept at least five years from the date of service². Authorized state and federal agencies may audit provider records, and a provider with electronic records must be able to produce them on paper within a reasonable time if AHCA asks². The BACB’s Ethics Code adds that behavior analysts keep detailed, high-quality documentation of their professional activities⁸.

These are other states’ audits, under those states’ rules, but the pattern is useful:

Other examples: a note saying “no modifications needed at this time” under 97155³; one saying to maintain the current protocol without modification⁴; 97155 billed for parent training, which that state did not cover⁴; in one case, notes that duplicated the previous session’s⁴; and, in another, notes with no start and end times or units⁴. In Wisconsin, 97156 notes sometimes showed a general conversation with the caregiver and no guidance on carrying out the protocol³.

The Indiana report also notes that a coalition’s industry guidance may have caused confusion about when to bill 97155⁵.

Florida’s policy describes the services, and the OIG tells us what it looked for. The last column is Wisconsin’s own rule, an example of how a state can spell it out, not a Florida requirement.

The OIG’s own description fits the policy’s wording: it describes 97155 as implementing a protocol modification and 97156 as guidance to parents to implement protocols⁵. For Florida, item five of section 6.2.4 is worded “if included”, while the policy defines 97155 as a service with modifications. How those two fit together in a given claim is a question for your plan.

The policy is the December 2024 version, in effect since February 10, 2025¹. Rule 59G-1.054 has been in its current version since May 8, 2017². The documentation rules of Colorado, Indiana and Wisconsin are not Florida’s, and your SMMC plan may ask for its own formats or add requirements. Not legal, clinical or billing advice: confirm with your plan, the BACB or an attorney.