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.
9. `Record entries.'
A written report of each evaluation under subd. 6.
and the plan of care under subd. 8.
shall be entered in the applicant's or recipient's record at the time of admission or, if the individual is already in the facility, immediately upon completion of the evaluation or plan.
(c) Eligibility for non-institutional services.
Recipients under age 22 or over age 64 who are inpatients in a hospital IMD are eligible for MA benefits for services not provided through that institution and reimbursed to the hospital as hospital services under s. DHS 107.08
and this subsection.
(d) Patient's account.
Each recipient who is a patient in a state, county, or private psychiatric hospital shall have an account established for the maintenance of earned or unearned money payments received, including social security and SSI payments. The account for a patient in a state mental health institute shall be kept in accordance with s. 46.07
, Stats. The payee for the account may be the recipient, if competent, or a legal representative or bank officer except that a legal representative employed by a county department of social services or the department may not receive payments. If the payee of the resident's account is a legally authorized representative, the payee shall submit an annual report on the account to the U.S. social security administration if social security or SSI payments have been paid into the account.
(e) Professional services provided to hospital IMD inpatients.
In addition to meeting the conditions for provision of services listed under s. DHS 107.08 (4)
, including separate billing, the following conditions apply to professional services provided to hospital IMD inpatients:
Diagnostic interviews with the recipient's immediate family members shall be covered services. In this subdivision, “immediate family members" means parents, guardian, spouse and children or, for a child in a foster home, the foster parents;
Electroconvulsive therapy shall be a covered service only when provided by a certified psychiatrist in a hospital setting.
(f) Non-covered services.
The following services are not covered services:
Activities which are primarily diversional in nature such as services which act as social or recreational outlets for the recipient;
Mild tranquilizers or sedatives provided solely for the purpose of relieving the recipient's anxiety or insomnia;
Conditional leave, convalescent leave or transfer days from psychiatric hospitals for recipients under the age of 21;
Psychotherapy or AODA treatment services when separately billed and performed by masters level therapists or AODA counsellors certified under s. DHS 105.22
Group therapy services or medication management for hospital inpatients whether separately billed by an IMD hospital or by any other provider as an outpatient claim for professional services;
Court appearances, except when necessary to defend against commitment; and
Inpatient services for recipients between the ages of 21 and 64 when provided by a hospital IMD, except that services may be provided to a 21 year old resident of a hospital IMD if the person was a resident of that institution immediately prior to turning 21 and continues to be a resident after turning 21. A hospital IMD patient who is 21 to 64 years of age may be eligible for MA benefits while on convalescent leave from a hospital IMD.
DHS 107.13 Note
Note: Subdivision 8 applies only to services for recipients 21 to 64 years of age who are actually residing in a psychiatric hospital or an IMD. Services provided to a recipient who is a patient in one of these facilities but temporarily hospitalized elsewhere for medical treatment or temporarily residing at a rehabilitation facility or another type of medical facility are covered services.
DHS 107.13 Note
For more information on non-covered services, see ss. DHS 107.03
and 107.08 (4)
DHS 107.13(2)(a)(a) Covered services.
Except as provided in par. (b)
, outpatient psychotherapy services shall be covered services when provided by a provider certified under s. DHS 105.22
, and when the following conditions are met:
A strength-based assessment, including differential diagnostic examination, is performed by a certified psychotherapy provider. A physician's prescription is not necessary to perform the assessment. The assessment shall include:
Diagnosis established from the current Diagnostic and Statistical Manual of Mental Disorders including all 5 axes or, for children up to age four, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.
The recipient's strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive function; past and present trauma; and substance abuse.
The recipient's unique perspective and own words about how he or she views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.
Barriers and strengths to the recipient's progress and independent functioning.
A provider who is a licensed physician, licensed psychologist, or a licensed and certified advanced practice nurse prescriber who is individually certified under s. DHS 105.22 (1) (a)
, or (bm)
and who is working in an outpatient mental health clinic certified under s. DHS 105.22
or in private practice.