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- 4: date, time, location and duration; maladaptive behaviors observed; replacement skills targeted; the recipient's response; any protocol modification or therapist direction; an explanation if the parent or guardian was absent; and participants.
- 054 requires each medical record to be signed and dated within two business days from the date and time of service, or otherwise authenticated.
- , limits consideration of addenda to those made before notification of the audit, germane to the note, and attached to a contemporaneous note.
The required elements (Florida Medicaid)
Section 6.2.4 of the Florida Medicaid Behavior Analysis Services Coverage Policy says session notes must be signed and dated by the rendering practitioner and must include:
- Date, time, location, and duration of services
- Maladaptive behaviors observed during the session
- The replacement/compensatory skills targeted during the session
- Description of the recipient's response to the treatment interventions
- Protocol modification, changes to goals/objectives, and/or therapist directions provided during the session, if included
- Explanation if the recipient's parent or guardian is not present during BA service delivery
- Participants, including observers, teachers, parents, caregivers, or other health care providers if present
Providers must also protect the confidentiality of other participants receiving services in a group setting.
General Medicaid rules that also apply
Rule 59G-1.054 applies to all Florida Medicaid providers. It requires that medical records establish the medical necessity for and the extent of services, and that each record be signed and dated within two business days from the date and time of service, or otherwise authenticated by signature, written initials or computer entry. Electronic signatures are allowed as defined in Chapter 668, Part I, F.S. Records must be accessible, legible and comprehensible, and kept at least five years from the date of service.
Section 409.913(7)(f), F.S., adds that claimed services must be documented by records made at the time the services were provided. In an overpayment case, the agency relies on contemporaneous records. It considers addenda only if they were made before notice of the audit, are germane to the note, and are attached to a note that was itself contemporaneous (409.913(21)–(22)).
Tip. Check the cited source for the current version before you change a billing process.
Parent participation is a documentation item
Section 4.2.2 says the parent or guardian should participate when possible and clinically appropriate. The provider must make every effort to accommodate that and document those efforts in treatment plan updates. If participation is not possible, the treatment plan and session notes must document the reasons, the potential impact, and how the impact is being mitigated. Authorization requests for continued services must include data about parent or guardian participation (7.2).
The gaps that cause trouble
| Gap | Why it matters |
|---|---|
| Start or stop time missing or rounded | Duration drives units. Florida bills 15-minute units with an 8-minute threshold (8.2), so the units must follow from the documented minutes. |
| Location missing or inconsistent with place of service | Location is a required element and must agree with the claim. |
| Signed after two business days | Fails Rule 59G-1.054(2)(a)2. |
| Copy-paste narrative | Does not describe this session's behaviors or response, which weakens medical necessity. |
| No targets from the behavior plan | Skills targeted should connect to the plan's goals and objectives. |
| Parent absent, no explanation | Required by 6.2.4 and 4.2.2. |
| Participants not listed | Required, and it is how a reviewer sees supervision or caregiver presence. |
| 97155 note with no modification or direction | The code is protocol modification, so the note should show one. |
A practical note template
- Header: recipient, date, start and end time, location (and place of service), rendering practitioner and credential, service code.
- Participants: everyone present, including the parent, or the reason the parent was not there.
- Behaviors observed: the plan's target behaviors, with data.
- Skills targeted: the plan's replacement or acquisition targets worked on.
- Response: how the recipient responded, in this session's terms.
- Changes: any protocol modification or direction given, and by whom.
- Signature: rendering practitioner, dated, within two business days.
That list is short enough to check automatically. A pre-claim note check reads each note, confirms every required element is there and consistent with the claim line, and sends the gaps back to the clinician before billing.
Watch out. Payer contracts and plan manuals can add requirements beyond the rules summarized here.
FAQ
What must an ABA session note include in Florida?
Per coverage policy section 6.2.4: date, time, location and duration; maladaptive behaviors observed; replacement skills targeted; the recipient's response; any protocol modification or therapist direction; an explanation if the parent or guardian was absent; and participants. The note must be signed and dated by the rendering practitioner.
How soon must an ABA session note be signed in Florida Medicaid?
Rule 59G-1.054 requires each medical record to be signed and dated within two business days from the date and time of service, or otherwise authenticated.
Can I add to a session note after an audit starts?
Section 409.913(22), F.S., limits consideration of addenda to those made before notification of the audit, germane to the note, and attached to a contemporaneous note.
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Related guides
Sources
- AHCA, Florida Medicaid Behavior Analysis Services Coverage Policy (Dec 2024), incorporated in Rule 59G-4.125, F.A.C.
- Rule 59G-1.054, F.A.C., Recordkeeping and Documentation Requirements
- Section 409.913, Florida Statutes (Oversight of the integrity of the Medicaid program)
Last reviewed October 2026. This page summarizes public rules and vendor pages for education; it is not legal or billing advice. Payer contracts and plan manuals can add requirements, so confirm with the payer.