Penguin Health

Wisconsin · ForwardHealth · Behavioral treatment benefit

Wisconsin tells you exactly what a session note must contain

Most states leave documentation to a general recordkeeping rule. Wisconsin does not. The ForwardHealth Behavioral Treatment Policy Handbook lists, code by code, the elements a note must carry for the service to be reimbursable. In July 2025 the federal Office of Inspector General checked notes against those lists and found a problem in all 100 sampled enrollee-months. The matching rule set lives in the rules library in the Penguin Health app, and we update it when the handbook changes.

See it on your Wisconsin notes Get a demo account Jump to the element lists

In the rules libraryWisconsin ABA · seventeen rules · maintained by Penguin · reviewed Oct 5, 2026

Improper payments, 2021 to 2022$18.5M

OIG's low estimate. Wisconsin was asked to refund the $12.2M federal share.

Potentially improper payments$94.3M

Set aside for the state to review claim by claim.

Sampled enrollee-months with a problem100 of 100

Across 22 ABA facilities and 98 children.

Wisconsin's Medicaid ABA spend$82.3M

In 2023, up from $39.9M in 2018.

OIG audit A-06-23-01002

Where the 100 sampled months failed

OIG pulled 100 enrollee-months from 22 facilities, worth $389,997, and asked for five things behind every unit paid: the prior authorization, the diagnostic evaluation, the prescription, the plan of care, and the session notes. Then it read the notes against the handbook's element lists.

Counts are enrollee-months out of 100. Most months failed more than one way. Hover or tab to a bar for what OIG actually saw.

Improper96 of 100Payments OIG says did not meet documentation requirements. These drive the refund.

Note did not support the CPT code billed79
79 months, 19 facilitiesMostly 97155. Of the 95 months that billed it, 75 had notes showing no issue resolved and no protocol change. One read "participated in social group during session and discrete trial was not conducted, no modifications needed at this time."
Note did not support the units billed77
77 months, 18 facilitiesThree causes: notes signed before the session ended (53 months), units exceeding the documented time (31), and 97153 paid concurrently with 97155 (17). One note documented 12:30 to 2:30, eight units; the claim was paid for ten.
Session notes missing for paid dates16
16 months, 11 facilitiesThe facility could not locate notes for one or more dates of service that Medicaid had already paid.
No rendering provider signature9
9 months, 7 facilitiesWithout a signature at the time services were rendered, OIG could not confirm who authored the note or that the service happened as documented.

050100

Potentially improper100 of 100Payments OIG could not verify from the note. Set aside for Wisconsin to review.

Note lacked a complete description, goals, or data100
100 months, 22 facilitiesEvery sampled month. One note carried no data at all and read only that the child "had a very good day and played well with all of his friends." Seven months had notes identical across multiple days, data included.
Described recreation with no technique documented93
93 months, 19 facilitiesOne note recorded only that the child spent time playing basketball, playing with dinosaurs, using an iPad, playing outside in a sandbox, swinging, and blowing bubbles, with no goal and no technique attached.
Included nontherapy time such as naps, lunch, travel85
85 months, 20 facilitiesABA billed continuously across the child's whole day. At one facility 23 sampled months had notes recording a nap or a meal, with the full block still billed and no start or end time for the nap.
Claim named the wrong rendering provider54
54 months, 14 facilitiesThe claim named a supervisor or therapist while the note showed a technician delivered the service. Focused treatment pays by the renderer's level, so the higher rate was paid. The usual cause was copying a commercial payer's claim format.

050100

Source: OIG A-06-23-01002, Findings and Appendix D. "Improper" and "potentially improper" are OIG's categories. 71 of the 100 months also had at least one allowable claim line.

View as a table

OIG category	Finding	Enrollee-months	Facilities
Improper	Note did not support the CPT code billed	79	19
Improper	97155 showed no issue resolved and no protocol change (of 95 months billing it)	75	n/a
Improper	97156 documented only a general discussion, or no caregiver present (of 70 billing it)	8	n/a
Improper	97151 showed activity unrelated to clinical assessment (of 48 billing it)	4	n/a
Improper	Note did not support the units billed	77	18
Improper	Note signed more than 8 minutes before the session ended	53	5
Improper	Units billed exceeded the time documented	31	10
Improper	97153 paid concurrently with 97155	17	11
Improper	Session notes missing for paid dates of service	16	11
Improper	No rendering provider signature	9	7
Potentially improper	Note lacked a complete description, the goals addressed, or data collected	100	22
Potentially improper	Described recreational activity with no ABA technique documented	93	19
Potentially improper	Included potential nontherapy time	85	20
Potentially improper	Claim named a rendering provider other than the one in the note	54	14
Potentially improper	Notes identical across multiple days	7	5

The element lists

What Wisconsin requires, code by code

This is the part other states do not give you. ForwardHealth states that for a service to be reimbursable, providers are required to document all of the following, and then lists them. Five elements apply to every code. Each code adds its own.

A heading with nothing under it does not satisfy a requirement, and a note missing one element is not reimbursable regardless of how good the rest of it is.

Required on every behavioral treatment note

Date of service
Length of the session, including time in and time out
Mode of delivery, in-person or telehealth
Names of staff that were present
The renderer's signature and signature date

97153Treatment by protocol · Topic #24004

The five universal elements
Measurable goals addressed
Therapeutic techniques used and data collected

The narrative and data must substantiate the time spent across the entire session. Data kept on a sheet or in an electronic system must be referenced, but need not be copied into the note.

97155Protocol modification · Topic #18980

The five universal elements
Measurable goals addressed with the member
Therapeutic techniques used and data collected
Issues resolved and/or changes made to the treatment protocol

The last element is the one that failed 75 times in the audit. The member must be in active treatment during the service.

97151Assessment and plan of care · Topic #18979

The five universal elements
The specific assessment activities performed: assessments administered, scored and interpreted, face-to-face time, data analyzed, records reviewed, or development of the plan of care

Documentation should specify the approximate time spent on each task, totaling the units billed. At least half the assessment time should be face-to-face with the member.

97156Family treatment guidance · Topic #18999

The five universal elements, with the caregivers present named
A note that the purpose was family treatment guidance
Treatment information collected from the family
Treatment information shared with the family
Measurable family goals addressed
Progress toward family goals
Updated family goals resulting from the session

Only the licensed supervisor may provide family treatment guidance, and must be the rendering provider on the claim. A team meeting is the same code with modifier AM and its own element list.

The 97155 problem

The code that failed in 75 of 95 months

97155 is 22 percent of Wisconsin's ABA spend and the single largest improper-payment category in the audit. Unlike most states, Wisconsin names in writing the four things that do not support the code, which makes this checkable rather than a matter of opinion.

Supports 97155

A licensed supervisor or treatment therapist delivered it and is the rendering provider.
The member was in active treatment from a technician, therapist, or the supervisor during the service.
An issue was resolved or a change was made to the existing treatment protocol or plan of care, and the note says what it was.
The note carries its elements: goals addressed, techniques and data, plus the change itself.
97153 was not billed for the same minutes during simultaneous direction of the technician.

Does not support 97155

A visit with the licensed supervisor with no documented protocol-modification activity.
Observing treatment staff without documenting resolved issues or protocol changes.
Direct treatment by the supervisor with no resolved issue or protocol change documented.
Informal assessment of the member's progress.

"Participated in social group during session and discrete trial was not conducted, no modifications needed at this time." A 97155 session note quoted in the audit. A second noted the supervisor observed no barriers, the child had "high compliance for completion," and next steps were to "continue with current targets." Both document that the code did not apply.

Supervision

Three separate clocks, one with a recoupment trigger

Wisconsin states three supervision requirements that are not interchangeable. The supervisor visit is the one to watch: it is the only requirement in the benefit where the handbook names the consequence of missing it, and the exposure is not just the supervisor's time but every hour of treatment delivered after the deadline.

The supervisor visit clock starts at the member's first date of direct treatment. Past day 75, ForwardHealth may recoup all payments for services delivered until the next visit occurs, so a single missed observation can expose a whole caseload's technician hours. Incidental observation during family training does not satisfy it.

In the rules library

Seventeen Wisconsin rules, ready to turn on

Open the rules library in the Penguin Health app, choose Wisconsin ABA, and add the set to your organization. Penguin reads session notes from CentralReach and runs the set on every note. Because Wisconsin publishes element lists, four of these rules are deterministic field checks rather than judgment calls.

The set is maintained by Penguin. When ForwardHealth updates the handbook, we change the rule, cite the topic that changed it, and date the review, so every organization on the set is running the current rules without rebuilding them.

Rules libraryPenguin Health app

Wisconsin ABAMaintained by Penguin

Seventeen rules for the ForwardHealth behavioral treatment benefit, each with QA guidance by program code.

reviewed: Oct 5, 2026
sources: Behavioral Treatment Policy Handbook, published policy through Dec 31, 2025 · Wis. Admin. Code ch. DHS 106 and § DHS 107.02 · OIG A-06-23-01002
watching: Handbook revisions to 97155 documentation guidance · DHS postpayment and prepayment audit program

Add to organizationAdds all seventeen rules and their QA guidance. Edit any rule afterward, or add your own alongside them.

Wisconsin requirement	What Penguin checks on every note	Handbook source	How
Required elements by codeRule 1	Each code's own element list, judged on content rather than headings. 97155 must carry the protocol change; 97156 must carry the family goals and the progress toward them.	Topics #24004, #18980, #18979, #18999	AI
97155 is a real protocol modificationRule 2	The narrative names the issue resolved or the change made, and shows the member in active treatment. The four handbook exclusions fail.	Topic #18980 · OIG finding, 75 months	AI
48-hour documentation deadlineRule 3	The renderer's signature date is within 48 hours of the date of service.	Topics #24004, #18980, #18979, #18999	Deterministic
Signature not before the session endsRule 4	Signed no earlier than 8 minutes before the session end time, the unit midpoint Wisconsin scored against.	AMA midpoint guidance, accepted by DHS · OIG finding, 53 months	Deterministic
Units match documented timeRule 5	Billed minutes equal time in to time out. No tolerance.	DHS 106.02(9)(a) · OIG finding, 31 months	Deterministic
No concurrent 97153 and 97155Rule 6	No minute of 97153 overlaps a minute of 97155 for the same member on the date.	Topics #24023, #18959 · OIG finding, 17 months	AI
Rendering provider matches the noteRule 7	The person who delivered the service is the rendering provider on the claim, with their specialty level named. Focused treatment pays by that level.	Topic #19637 · OIG finding, 54 months	AI
Recreation carries goals and techniquesRule 8	Recreation and daily-living activity pass only with the goal targeted and the technique used. Sleeping during billed time fails outright.	Topics #24004, #19020 · OIG finding, 93 months	AI
No travel, breaks, or documentation timeRule 9	Travel, case management, and note-writing inside the billed window flag.	Topic #19020 · OIG finding, 85 months	AI
Narrative is individualizedRule 10	An exact duplicate of any narrative in the organization in the last seven days fails, across members, staff, and codes.	CMS cloned-note guidance · OIG finding, 7 months	Deterministic
Service limits by codeRule 11	Per-date and per-period caps: 2 hours for family guidance and group, 1 hour per week for team meetings, 96 units a year for assessment.	Topics #18959, #18999, #22657	AI
Supervisor visit every 60 to 75 daysRule 12	A qualifying one-hour observation within 75 days, documented with member-focused activities. Incidental observation during family training does not count.	Topic #19038, Supervisor Visit	AI
Face-to-face direction, 1 to 2 hours per 10Rule 13	Fails below the minimum, and fails above the maximum unless exceptional circumstances are documented. Averaged over the month.	Topic #19038, Face-to-Face Direction	AI
Professional supervision documentedRule 14	Monthly face-to-face for technicians; weekly contact plus monthly face-to-face for therapists.	Topic #19038, Professional Supervision · DHS 101.03(173)	AI
Place of service matches the settingRule 15	Includes Wisconsin's community convention: a park, library, or store is POS 12, not 99.	Topic #18958	AI
Group size and compositionRule 16	Two to eight members, led by a supervisor or therapist. A secondary assisting provider needs four or more. An undocumented group size fails.	Topic #22657	AI
Electronic signature under renderer controlRule 17	A dated signature belonging to the renderer. A signature applied by billing staff on their behalf fails.	Topic #16157 · Wis. Stat. § 137.11(8)	AI

Every failure ships with the fix for that program code: the educational email, numbered action steps, and the escalation email pre-filled with the date of service and staff name. Each reviewer action is written to a write-once audit log with seven-year retention, which matters in Wisconsin, where providers must retain records for at least five years from the date of payment and produce them on request. Billing Medicaid in more than one state? The rules library covers sixteen, including Minnesota and Indiana.

Maintained by Penguin

We watch ForwardHealth so the rules never go stale

Wisconsin republishes the Behavioral Treatment Policy Handbook continuously, and the state has told OIG it will rewrite the parts the audit faulted. The Wisconsin set is tied to those topics, not to a template written once.

Watch

The Behavioral Treatment Policy Handbook and its published-through date, ForwardHealth Updates and provider bulletins, Wis. Admin. Code ch. DHS 106 and 107, and the DHS Office of Inspector General's post-payment review materials.

Update

We rewrite the affected rule, cite the handbook topic that changed it, and date the review. The set shows its sources and review date in the library, so you can see it is current without asking us.

Re-run

An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.

Jan 2016
Wisconsin begins covering ABA
The behavioral treatment benefit launches with the handbook as the operative policy document, since the administrative code contains no ABA-specific criteria.
Jan 2019
CPT codes and treatment modifiers required
Every claim line needs a code plus TG for comprehensive or TF for focused treatment, with TF-52 where technicians deliver focused treatment.
Jul 10, 2025
OIG publishes the audit
All 100 sampled enrollee-months carried an improper or potentially improper payment. OIG made six recommendations, including that Wisconsin update its 97155 guidance to require documenting how issues were resolved.
LibraryRules 2, 4, 5, 6, 7, 8, 9, and 10 each cite a finding from this report.
Jul 2025
Wisconsin concurs with five of six recommendations
The state agreed to update the handbook and its guidance, to conduct postpayment audits, to evaluate prepayment audits, and to build a procedure verifying who rendered focused treatment so claims pay at the right level.
LibraryRule 7 checks the rendering provider and names the specialty level, which is the check the state said it would build.
Dec 31, 2025
Current handbook publication date
The Behavioral Treatment Policy Handbook in force, published policy through December 31, 2025, carries the per-code element lists, the 48-hour documentation deadline, and the supervision requirements this rule set is built from.
LibraryEvery rule cites this edition, so a reviewer can see which handbook a finding was judged against.
Oct 5, 2026
Wisconsin set reviewed
Checked against the handbook as published through December 31, 2025, and the OIG final report. Current.
Watching
Updated 97155 guidance and the audit program
Wisconsin told OIG it would update the handbook to require documenting how issues were resolved or what changed, and that it would begin postpayment audits while evaluating prepayment review of 97153. When either lands, the set is updated and every organization using it gets the change.

Next step

Run a month of Wisconsin notes through Penguin

Bring one month of 97153 and 97155 notes. We add the Wisconsin set from the rules library, run it, show every finding beside the handbook topic it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.

Book a demo Get a demo account

This page summarizes public documents for behavioral treatment providers in Wisconsin and is not legal or billing advice. Requirements change; everything here, and the Wisconsin ABA set in the Penguin Health rules library, was reviewed against the sources below on October 5, 2026. When a source changes, the set is updated and the review date moves with it. CPT is a registered trademark of the American Medical Association.

HHS OIG, Wisconsin Made at Least $18.5 Million in Improper Fee-For-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism, A-06-23-01002, July 2025 (findings, counts, quoted session notes, requirements cited, and Wisconsin's response)
ForwardHealth Behavioral Treatment Policy Handbook (PDF, 280 pages), published policy through December 31, 2025. Per-code documentation requirements at Topics #24004 (97153), #18980 (97155), #18979 (97151 and 97152), and #18999 (97156 and team meetings); the 48-hour documentation deadline in each of those topics; the supervisor visit and the face-to-face direction band on page 120 (Topic #19038); noncovered services at Topic #19020; place of service at Topic #18958; group treatment at Topic #22657; electronic signatures at Topic #16157
Wis. Admin. Code § DHS 106.02(9) (provider records and retention), § DHS 107.02(2) (services that do not meet program requirements), and § DHS 101.03(96m) (medical necessity), as quoted in sources 1 and 2
Wis. Stat. § 137.11(8), the electronic signature definition the handbook adopts
CMS, Documentation Matters fact sheet, Medicaid Documentation for Behavioral Health Practitioners, December 2015 (cloned notes), as cited in source 1