To the Department of Medical Assistance Services (DMAS):

This comment is submitted on behalf of stakeholders providing Applied Behavior Analysis (ABA) services to Virginia Medicaid members, with a request for Virginia Medicaid to re-evaluate its supervisory co-signature requirement as outlined in DMAS Mental Health Manual, Appendix D. This policy, which states,

"Documentation of all billed services shall include the amount of time or billable units spent to deliver the service and shall be signed and dated on the date of the service by the practitioner rendering the service and include any applicable supervisor co-signature,"

is incongruent with widely recognized industry standards for ABA documentation and introduces unnecessary inefficiencies without enhancing care quality.

As clarified by the Council of Autism Service Providers (CASP) in its Applied Behavior Analysis Practice Guidelines, ABA services function under distinct professional frameworks, separate from other forms of healthcare delivery that utilize "incident to" billing models. Specifically:

• ABA Documentation Standards: Session notes for behavior technician-provided services, including CPT codes 97152, 97153, and 97154, are designed to be signed solely by the rendering technician. CASP confirms that supervisory co-signatures on these notes are not standard or required in the field of ABA.
• Supervisory Oversight is Established Elsewhere: Supervising Board Certified Behavior Analysts (BCBAs) oversee ABA services through signed treatment plans and separate supervision documentation. These processes ensure that adequate oversight and accountability are maintained without imposing redundant requirements.
• Alignment with AMA CPT Guidelines: The CPT codes specific to ABA services reflect the independent and distinct nature of these services, demonstrating that co-signatures are not necessary for compliance.

Mandating BCBA co-signatures for every session note disrupts operational efficiencies without providing additional safeguards or quality improvements for Medicaid members. It also places undue administrative demands on providers, potentially diverting valuable resources away from direct patient care.

To this end, we strongly urge DMAS to align its policies with national best practices and clarify that behavior technician session notes can be properly documented with their signature alone, as supported by CASP and AMA CPT guidelines. Adopting this modification would modernize Medicaid policies and ensure they reflect the unique characteristics of ABA service provision.