4 Tips to Improve Clinical Documentation for ABA Clinics

Accurate clinical documentation is business critical, not only ensuring your clients get the right care at the right time but also that you are in compliance with CMS guidelines. Unfortunately, because of gaps in modern documentation, lapses in treatment for behavioral disorders often go undiscovered until after a client leaves. These lapses risk malpractice claims since failure to identify and remedy poor care while the client is present for services, weakens your ability to amend it.

When clients pay through Insurance as a funding source,insurance Payers scrutinize each session of Therapy. Weak documentation can lead Payers to deny coverage for the entirety of a client’s therapy. Precise documentation reduces denials by keeping an accurate and ordered record of medical needs and treatment before submission for payment.

Here are some best practices that will help you improve your clinical documentation for applied behavioral analysis (ABA).

Recognize Clinical Documentation Missteps

While documentation standards have improved in many areas, some pieces of information consistently receive less attention than needed. Here are some areas often overlooked by clinicians.

• Necessity: With insurance payments, Payers are thorough in their review of medical necessity. As such, documents must show therapist’s judgment and logical plan in describing treatment protocols. ‍
• Critical care elements: Once you have established necessity, accurately label every treatment under the needed category.
• ‍Progress report: Keep records of a client’s progress over time. Also, detail the evaluation method used to make assessments.
• ‍Consent: Informed consent from the parent or guardian is integral to achieving reimbursement. These forms are necessary for tele-aba as well in addition to therapy in more traditional settings like Clinic, In-Home or at School.

Perform Internal Audits

External audits, especially from Payers, can cause significant financial and legal repercussions for an ABA practice. To prevent this, an ABA organization should have routine internal audits. Let your therapist team know when these audits will occur. Explain the standards you will be using to review the clinical documentation and how to achieve them. If your team fails an audit, construct a plan to reach your goals by a set date. Then, once the team consistently meets your standards, perform random audits through out the year.

Increase Automation

Robust automated systems such as electronic health records (EHRs) are integral to ABA clinical documentation. In addition, these systems give clinics access to records from other locations reducing the amount of repetitive paperwork.

Ambient computing is a type of artificial intelligence programmed to comprehend and fulfill human needs. An example is an ambient clinical intelligence (ACI) developed by Nuance and Microsoft. This software is trained to observe a clinician and client interaction. Then, it will parse out the relevant information and automatically enter it into the EHR.  

Programs like this ACI are crucial to the future. A 2019 study shows physicians claim 40% of burnout from EHRs. According to Nuance’s website, physicians report the program reduced burnout by 70%. While still impractical for most small to mid-sized practices, modern ambient computing is a leap toward increasing efficiency and reducing clinician fatigue.

Improve Training

Automation is the future of clinical documentation. However,currently, these systems can only function with human accompaniment. Also technology is only an enabler for the clinician, and can never be are placement.

Plutus Health works with you to streamline not only medical billing, but also provides inputs on better clinical documentation. If you are struggling with billing, collection, and denials management, our expert team takes care to get faster and the best reimbursement possible and increase your practice’s performance.

Key Takeaways

1.      Importance of clinical documentation and impacts of External Audits

2.      Learn crucial areas of information that can prevent denials.

3.      Schedule routine internal audits.

4.     Adopt modern technology to reduce clinician stress and increase efficiency.

5.      Ensure your staff learns and adapts to modern standards of practice.