Unnecessary or inappropriate inpatient admissions or portions of a stay;
Hospitalizations or portions of hospitalizations disallowed by the PRO;
Hospitalizations either for or resulting in surgeries which the department views as experimental due to questionable or unproven medical effectiveness;
Inpatient services and outpatient services for the same patient on the same date of service unless the patient is admitted to a hospital other than the facility providing the outpatient care;
Hospital admissions on Friday or Saturday, except for emergencies, accident or accident care and obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week; and
Hospital laboratory, diagnostic, radiology and imaging tests not ordered by a physician, except in emergencies;
Neither MA nor the recipient may be held responsible for charges or services identified in par. (a)
as non-covered, except that a recipient may be billed for charges under par. (a) 3.
, if the recipient was notified in writing in advance of the hospital stay that the service was not a covered service.
If hospital services for a patient are no longer medically necessary and an appropriate alternative care setting is available but the patient refuses discharge, the patient may be billed for continued services if he or she receives written notification prior to the time medically unnecessary services are provided.
The following professional services are not covered as part of a hospital inpatient claim but shall be billed by an appropriately certified MA provider;
Services of physicians, including pathologists, radiologists and the professional-billed component of laboratory and radiology or imaging services, except that services by physician intern and residents services are included as hospital services;
Services of psychiatrists and psychologists, except when performing group therapy and medication management, including services provided to a hospital inpatient when billed by a hospital, clinic or other mental health or AODA provider;
Services of nurse midwives, nurse practitioners and independent nurses when functioning as independent providers;
Professional services provided to hospital inpatients are not covered hospital inpatient services but are rather professional services and subject to the requirements in this chapter that apply to the services provided by the particular provider type.
Neither a hospital nor a provider performing professional services to hospital inpatients may impose an unauthorized charge on recipients for services covered under this chapter.
DHS 107.08 Note
For more information on non-covered services, see s. DHS 107.03
DHS 107.08 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; am. (4) (e) and (f), cr. (4) (g), Register, February, 1988, No. 388
, eff. 3-1-88; correction in (3) (g) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 1990, No. 414
; emerg. renum. (4) to be (4) (a) and am. (4) (a) (intro.) 1., 2., 4., 6. and 7., cr. (4) (b) to (f) eff. 1-1-91; r. and recr. Register, September, 1991, No. 429
, eff. 10-1-91; correction in (2) (d) made under s. 13.93 (2m) (b) 7., Register August 2006 No. 608
; corrections in (1) and (3) (c) 1., made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
In this section, “active treatment" means an ongoing, organized effort to help each resident attain his or her developmental capacity through the resident's regular participation, in accordance with an individualized plan, in a program of activities designed to enable the resident to attain the optimal physical, intellectual, social and vocational levels of functioning of which he or she is capable.
(2) Covered services.
Covered nursing home services are medically necessary services provided by a certified nursing home to an inpatient and prescribed by a physician in a written plan of care. The costs of all routine, day-to-day health care services and materials provided to recipients by a nursing home shall be reimbursed within the daily rate determined for MA in accordance with s. 49.45 (6m)
, Stats. These services are the following:
Special care services, including activity therapy, recreation, social services and religious services;
Supportive services, including dietary, housekeeping, maintenance, institutional laundry and personal laundry services, but excluding personal dry cleaning services;
Physical plant, including depreciation, insurance and interest on plant;
Personal comfort items, medical supplies and special care supplies. These are items reasonably associated with normal and routine nursing home services which are listed in the nursing home payment formula. If a recipient specifically requests a brand name which the nursing home does not routinely supply and for which there is no equivalent or close substitute included in the daily rate, the recipient, after having been informed in advance that the equivalent or close substitute is not available without charge, will be expected to pay for that brand item at cost out of personal funds; and
Indirect services provided by independent providers of service.
DHS 107.09 Note
Note: Copies of the Nursing Home Payment Formula may be obtained from Records Custodian, Division of Health Care Access and Accountability, P.O. Box 309, Madison, Wisconsin 53701.
DHS 107.09 Note
Note: Examples of indirect services provided by independent providers of services are services performed by a pharmacist reviewing prescription services for a facility and services performed by an occupational therapist developing an activity program for a facility.
(3) Services requiring prior authorization.
The rental or purchase of a specialized wheelchair for a recipient in a nursing home, regardless of the purchase or rental cost, requires prior authorization from the department.
DHS 107.09 Note
For more information on prior authorization, see s. DHS 107.02 (3)
Treatment costs which are both extraordinary and unique to individual recipients in nursing homes shall be reimbursed separately as ancillary costs, subject to any modifications made under sub. (2) (b)
. The following items are not included in calculating the daily nursing home rate but may be reimbursed separately:
Oxygen in liters, tanks, or hours, including tank rentals and monthly rental fees for concentrators;
Tracheostomy and ventilatory supplies and related equipment, subject to guidelines and limitations published by the department in the provider handbook;
Transportation of a recipient to obtain health treatment or care if the treatment or care is prescribed by a physician as medically necessary and is performed at a physician's office, clinic, or other recognized medical treatment center, if the transportation service is provided by the nursing home, in its controlled equipment and by its staff, or by common carrier such as bus or taxi, and if the transportation service was provided prior to July 1, 1986. Transportation shall not be reimbursed as an ancillary service on or after July 1, 1986; and
Direct services provided by independent providers of service only if the nursing home can demonstrate to the department that to pay for the service in question as an add-on adjustment to the nursing home's daily rate is equal in cost or less costly than to reimburse the independent service provider through a separate billing. The nursing home may receive an ancillary add-on adjustment to its daily rate in accordance with s. 49.45 (6m) (b)
, Stats. The independent service provider may not claim direct reimbursement if the nursing home receives an ancillary add-on adjustment to its daily rate for the service.
The costs of services and materials identified in subd. 1.
which are provided to recipients shall be reimbursed in the following manner:
Claims shall be submitted under the nursing home's provider number, and shall appear on the same claim form used for claiming reimbursement at the daily nursing home rate;
The items identified in subd. 1.
shall have been prescribed in writing by the attending physician, or the physician's entry in the medical records or nursing charts shall make the need for the items obvious;
The amounts billed shall reflect the fact that the nursing home has taken advantage of the benefits associated with quantity purchasing and other outside funding sources;
Reimbursement for questionable materials and services shall be decided by the department;
Claims for transportation shall show the name and address of any treatment center to which the patient recipient was transported, and the total number of miles to and from the treatment center; and
The amount charged for transportation may not include the cost of the facility's staff time, and shall be for an actual mileage amount.
(b) Independent providers of service.
Whenever an ancillary cost is incurred under this subsection by an independent provider of service, reimbursement may be claimed only by the independent provider on its provider number. The procedures followed shall be in accordance with program requirements for that provider specialty type.
(c) Services covered in a Christian Science sanatorium.
Services covered in a Christian Science sanatorium shall be services ordinarily received by inpatients of a Christian Science sanatorium, but only to the extent that these services are the Christian Science equivalent of services which constitute inpatient services furnished by a hospital or skilled nursing facility.
Wheelchairs shall be provided by skilled nursing and intermediate care facilities in sufficient quantity to meet the health needs of patients who are recipients. Nursing homes which specialize in providing rehabilitative services and treatment for the developmentally or physically disabled, or both, shall provide the special equipment, including commodes, elevated toilet seats, grab bars, wheelchairs adapted to the recipient's disability, and other adaptive prosthetics, orthotics and equipment necessary for the provision of these services. The facility shall provide replacement wheelchairs for recipients who have changing wheelchair needs.
(e) Determination of services as skilled.
In determining whether a nursing service is skilled, the following criteria shall be applied:
Where the inherent complexity of a service prescribed for a patient is such that it can be safely and effectively performed only by or under the direct supervision of technical or professional personnel, the service shall constitute a skilled service;
The restoration potential of a patient shall not be the deciding factor in determining whether a service is to be considered skilled or nonskilled. Even where full recovery or medical improvement is not possible, skilled care may be needed to prevent, to the extent possible, deterioration of the condition or to sustain current capacities. For example, even though no potential for rehabilitation exists, a terminal cancer patient may require skilled services as defined in this paragraph and par. (f)
A service that is ordinarily nonskilled shall be considered a skilled service where, because of medical complications, its performance or supervision or the observation of the patient necessitates the use of skilled nursing or skilled rehabilitation personnel. For example, the existence of a plaster cast on an extremity generally does not indicate a need for skilled care, but a patient with a preexisting acute skin problem or with a need for special traction of the injured extremity might need to have technical or professional personnel properly adjust traction or observe the patient for complications. In these cases, the complications and special services involved shall be documented by physician's orders and nursing or therapy notes.
(f) Skilled nursing services or skilled rehabilitation services. DHS 107.09(4)(f)1.1.
A nursing home shall provide either skilled nursing services or skilled rehabilitation services on a 7-day-a-week basis. If, however, skilled rehabilitation services are not available on a 7-day-a-week basis, the nursing home would meet the requirement in the case of a patient whose inpatient stay is based solely on the need for skilled rehabilitation services if the patient needs and receives these services on at least 5 days a week.
DHS 107.09 Note
Note: For example, where a facility provides physical therapy on only 5 days a week and the patient in the facility requires and receives physical therapy on each of the days on which it is available, the requirement that skilled rehabilitation services be provided on a daily basis would be met.
Examples of services which could qualify as either skilled nursing or skilled rehabilitation services are:
Overall management and evaluation of the care plan. The development, management and evaluation of a patient care plan based on the physician's orders constitute skilled services when, in terms of the patient's physical or mental condition, the development, management and evaluation necessitate the involvement of technical or professional personnel to meet needs, promote recovery and actuate medical safety. This includes the management of a plan involving only a variety of personal care services where in light of the patient's condition the aggregate of the services necessitates the involvement of technical or professional personnel. Skilled planning and management activities are not always specifically identified in the patient's clinical record. In light of this, where the patient's overall condition supports a finding that recovery or safety can be assured only if the total care required is planned, managed, and evaluated by technical or professional personnel, it is appropriate to infer that skilled services are being provided;
Observation and assessment of the patient's changing condition. When the patient's condition is such that the skills of a nurse or other technical or professional person are required to identify and evaluate the patient's need for possible modification of treatment and the initiation of additional medical procedures until the patient's condition is stabilized, the services constitute skilled nursing or rehabilitation services. Patients who in addition to their physical problems exhibit acute psychological symptoms such as depression, anxiety or agitation may also require skilled observation and assessment by technical or professional personnel for their safety and the safety of others. In these cases, the special services required shall be documented by a physician's orders or nursing or therapy notes; and
Patient education. In cases where the use of technical or professional personnel is necessary to teach a patient self-maintenance, the teaching services constitute skilled nursing or rehabilitative services.
Considered appropriate by the department and provided by a Christian Science sanatorium either operated by or listed and certified by the First Church of Christ Scientist, Boston, Mass.; or
Provided by a facility located on an Indian reservation that furnishes, on a regular basis, health-related services and is licensed pursuant to s. 50.03
, Stats., and ch. DHS 132
Intermediate care services may include services provided in an institution for developmentally disabled persons if:
The primary purpose of the institution is to provide health or rehabilitation services for developmentally disabled persons;
Intermediate care services may include services provided in a distinct part of a facility other than an intermediate care facility if the distinct part:
Is an identifiable unit, such as an entire ward or contiguous ward, a wing, a floor, or a building;