Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.
DHS 107.12 History
Cr. Register, February, 1986, No. 362
, eff. 3-1-86; emerg. r. and recr. eff. 7-1-90; r. and recr. Register, January, 1991, No. 421
, eff. 2-1-91; emerg. r. and recr. eff. 7-1-92; r. and recr. Register, February, 1993, No. 446
, eff. 3-1-93; CR 03-033
: am. (1) (e) Register December 2003 No. 576
, eff. 1-1-04; corrections in (1) (b) made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576
; CR 05-052
: r. (2) (b) and (3) (d), cr. (4) (f) and (g) Register June 2007 No. 618
, eff. 7-1-07; corrections in (1) (a) and (3) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636
Covered services provided by a certified nurse-midwife may include the care of mothers and their babies throughout the maternity cycle, including pregnancy, labor, normal childbirth and the immediate postpartum period, provided that the nurse-midwife services are provided within the limitations established in s. 441.15 (2)
, Stats., and ch. N 4
Coverage for nurse-midwife services for management and care of the mother and newborn child shall end after the sixth week of postpartum care.
DHS 107.121 History
Cr. Register, January, 1991, No. 421
, eff. 2-1-91.
DHS 107.122 Independent nurse practitioner services. DHS 107.122(1)(1)
Services provided by a nurse practitioner, including a clinical nurse specialist, which are covered by the MA program are those medical services delegated by a licensed physician by a written protocol developed with the nurse practitioner pursuant to the requirements set forth in s. N 6.03 (2)
and guidelines set forth by the medical examining board and the board of nursing. General nursing procedures are covered services when performed by a certified nurse practitioner or clinical nurse specialist in accordance with the requirements of s. N 6.03 (1)
. These services may include those medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a medical setting, the recipient's home or elsewhere. Specific reimbursable delegated medical acts and nursing services are the following:
Obtaining a recipient's complete health history and recording the findings in a systematic, organized manner;
Performing a complete physical assessment using techniques of observation, inspection, auscultation, palpation and percussion, ordering appropriate laboratory and diagnostic tests and recording findings in a systematic manner;
Performing and recording a developmental or functional status evaluation and mental status examination using standardized procedures; and
Identifying and describing behavior associated with developmental processes, aging, life style and family relationships;
Discriminating between normal and abnormal findings associated with growth and development, aging and pathological processes;
Discriminating between normal and abnormal patterns of behavior associated with developmental processes, aging, life style, and family relationships as influenced by illness;
Exercising clinical judgment in differentiating between situations which the nurse practitioner can manage and those which require consultations or referral; and
Providing preventive health care and health promotion for adults and children;
Managing common self-limiting or episodic health problems in recipients according to protocol and other guidelines;
Managing stabilized illness problems in coloration with physicians and other health care providers according to protocol;
Prescribing, regulating and adjusting medications as defined by protocol;
Counseling recipients and their families about the process of growth and development, aging, life crises, common illnesses, risk factors and accidents;
Helping recipients and their families assume greater responsibility for their own health maintenance and illness care by providing instruction, counseling and guidance;
Arranging referrals for recipients with health problems who need further evaluation or additional services; and
Modifying the therapeutic regimen so that it is appropriate to the developmental and functional statuses of the recipient and the recipient's family;
Collecting systematic data for evaluating the response of a recipient and the recipient's family to a therapeutic regimen;
Utilizing an epidemiological approach in examining the health care needs of recipients in the nurse practitioner's caseload;
Services under sub. (1) (e)
are subject to applicable prior authorization requirements for those services.
Requests for prior authorization shall be accompanied by the written protocol.
No services under this section may be reimbursed without a written protocol developed and signed by the nurse practitioner and the delegating physician, except for general nursing procedures described under s. N 6.03 (1)
. The physician shall review a protocol according to the requirements of s. 448.03 (2) (e)
, Stats., and guidelines established by the medical examining board and the board of nursing, but no less than once each calendar year. A written protocol shall be organized as follows:
Prescriptions for drugs are limited to those drugs allowed under protocol for prescription by a nurse practitioner, except that controlled substances may not be prescribed by a nurse practitioner.
Services provided to nursing home residents or hospital inpatients which are included in the daily rates for a nursing home or hospital;
Medical acts for which the nurse practitioner or clinical nurse specialist does not have written protocols as specified in this section. In this paragraph, “medical acts" means acts reserved by professional training and licensure to physicians, dentists and podiatrists.
DHS 107.122 History
Emerg. cr. eff. 7-1-90; cr. Register, January, 1991, No. 421
, eff. 2-1-91; correction in (1) (e) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520
(a) Covered services.
Inpatient hospital mental health and AODA care shall be covered when prescribed by a physician and when provided within a hospital institution for mental disease (IMD) which is certified under ss. DHS 105.07
, except as provided in par. (b)
Conditions for coverage of recipients under 21 years of age. DHS 107.13(1)(b)1.1. `Definition.'
In this paragraph, “individual plan of care"or “plan of care" means a written plan developed for each recipient under 21 years of age who receives inpatient hospital mental health or AODA care in a hospital IMD for the purpose of improving the recipient's condition to the extent that inpatient care is no longer necessary.
2. `General conditions.'
Inpatient hospital mental health and AODA services provided in a hospital IMD for recipients under age 21 shall be provided under the direction of a physician and, if the recipient was receiving the services immediately before reaching age 21, coverage shall extend to the earlier of the following:
For recipients under age 21 receiving services in a hospital IMD, a team specified in subd. 3. b.
shall certify that ambulatory care resources do not meet the treatment needs of the recipient, proper treatment of the recipient's psychiatric condition requires services on an inpatient basis under the direction of a physician, and the services can reasonably be expected to improve the recipient's condition or prevent further regression so that the services will be needed in reduced amount or intensity or no longer be needed. The certification specified in this subdivision satisfies the requirement for physician certification in subd. 7.
In this subparagraph, “ambulatory care resources" means any covered service except hospital inpatient care or care of a resident in a nursing home.
Certification under subd. 3. a.
shall be made for a recipient when the person is admitted to a facility or program by an independent team that includes a physician. The team shall have competence in diagnosis and treatment of mental illness, preferably in child psychology, and have knowledge of the recipient's situation.
For a recipient who applies for MA eligibility while in a facility or program, the certification shall be made by the team described in subd. 5. b.
and shall cover any period before application for which claims are made.
For emergency admissions, the certification shall be made by the team specified in subd. 5. b.
within 14 days after admission.
4. `Active treatment.'
Inpatient psychiatric services shall involve active treatment. An individual plan of care described in subd. 5.
shall be developed and implemented no later than 14 days after admission and shall be designed to achieve the recipient's discharge from inpatient status at the earliest possible time.
The individual plan of care shall be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the recipient's situation and reflects the need for inpatient psychiatric care; be developed by a team of professionals specified under subd. 5. b.
in consultation with the recipient and parents, legal guardians or others into whose care the recipient will be released after discharge; specify treatment objectives; prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; and include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient's family, school and community upon discharge.
The individual plan of care shall be developed by an interdisciplinary team that includes a board-eligible or board-certified psychiatrist; a clinical psychologist who has a doctorate and a physician licensed to practice medicine or osteopathy; or a physician licensed to practice medicine or osteopathy who has specialized training and experience in the diagnosis and treatment of mental diseases, and a psychologist who has a master's degree in clinical psychology or who is certified by the state. The team shall also include a psychiatric social worker, a registered nurse with specialized training or one year's experience in treating mentally ill individuals, an occupational therapist who is certified by the American occupation therapy association and who has specialized training or one year of experience in treating mentally ill individuals, or a psychologist who has a master's degree in clinical psychology or who has been certified by the state. Based on education and experience, preferably including competence in child psychiatry, the team shall be capable of assessing the recipient's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; assessing the potential resources of the recipient's family; setting treatment objectives; and prescribing therapeutic modalities to achieve the plan's objectives.
The plan shall be reviewed every 30 days by the team specified in subd. 5. b.
to determine that services being provided are or were required on an inpatient basis, and to recommend changes in the plan as indicated by the recipient's overall adjustment as an inpatient.
The development and review of the plan of care under this subdivision shall satisfy the utilization control requirements for physician certification and establishment and periodic review of the plan of care.
Before a recipient is admitted to a psychiatric hospital or before payment is authorized for a patient who applies for MA, the attending physician or staff physician shall make a medical evaluation of each applicant's or recipient's need for care in the hospital, and appropriate professional personnel shall make a psychiatric and social evaluation of the applicant's or recipient's need for care.
Each medical evaluation shall include a diagnosis, a summary of present medical findings, medical history, the mental and physical status and functional capacity, a prognosis, and a recommendation by a physician concerning admission to the psychiatric hospital or concerning continued care in the psychiatric hospital for an individual who applies for MA while in the hospital.
A physician shall certify and recertify for each applicant or recipient that inpatient services in a psychiatric hospital are or were needed.
The certification shall be made at the time of admission or, if an individual applies for assistance while in a psychiatric hospital, before the agency authorizes payment.
Before a recipient is admitted to a psychiatric hospital or before payment is authorized, the attending physician or staff physician shall document and sign a written plan of care for the recipient or applicant. The physician's plan of care shall include diagnosis, symptoms, complaints and complications indicating the need for admission; a description of the functional level of the individual; objectives; any orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet or special procedures recommended for the health and safety of the patient; plans for continuing care, including review and modification to the plan of care; and plans for discharge.
The attending or staff physician and other personnel involved in the recipient's care shall review each plan of care at least every 30 days.