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• Please code to the most speciﬁc level possible.
• Severity of Symptoms (determined by the specialized diagnosing provider):
• Include statement of the level of severity (mild – level 1, moderate – level 2, severe – level 3).
• Example: Patient A was given a diagnosis of Autism Spectrum Disorder (F84.0), severity level 1 (mild) by Dr. Smith,
• Prescribed medications (if applicable)
• Medical Co-Morbidities (if applicable)
• Include a statement if the beneﬁciary does not have any other medical co-morbidities.
• Family History
• Include any family history and related family training in support of performing ABA therapy.
• Specify where the beneﬁciary lives and with whom (siblings, parents).
• Include any other relevant information about family stressors, such as medical history, active medical problems, current
medications, dose and purpose, allergies, and/or special diet.
• Length of Care
• Specify the amount of time the patient has been receiving ABA services (start date of entrance into the Autism Care
Demo to current).
• Location of Services
• Parent/Guardian Signature
• ABA Supervisor Name
• Use of PDD-BI for beneciaries under the age of 18.5. For benecaries over the age of 18.5 the ABA supervisor should
continue using the assessment already in process.
• Location of services (for example, school, at home, centerbase/clinic)
INITIAL ASSESSMENT: REQUIRED COMPONENTS
• Behavior Deﬁcits: Behavior deﬁcits are those that impede the beneﬁciary’s safe, healthy independent functioning in all
domains (socialization, communication, adaptive).
• Behavior deﬁcits must be objectively measured and identiﬁed.
• Include assessment notes (baseline/skill level at time of assessment) regarding the beneﬁciary’s performance when the initial
assessment was completed and baseline measures of the assessment tool utilized (for example, VB-MAPP) and speciﬁed
treatment interventions for identiﬁed target in each domain.
• Goals/Objectives: Goals and objectives must be speciﬁc, measurable (6 out of 10 opportunities, 8 out of 10 trials, etc.) and
the assessment tool domain must be identiﬁed (for example, VB-MAPP, Carolina, ABLLS).
• Goals are the broad spectrum, complex short-term and long-term desired outcomes of ABA.
• Objectives are the short, simple, measurable steps that must be accomplished in order to reach the short-term and long-term
goals of ABA.
• Include clearly deﬁned objectives and goals individualized to the strengths, needs and preferences of the beneﬁciary and his/
her family members.
• Identify long term goals (for example, six months in duration) and short-term objectives, such as the intermediary steps to
meet long term goal.
• Update goals with each reassessment and clearly note if met, not met or modiﬁed with an explanation.